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1 Postpartum Depression Prevention Jany Dominguez West Coast University NURS 691B: Culminating Experience II Dr. Tracy Macdonald November 26, 2023

2 Postpartum Depression Prevention One issue that affects many women who have recently given birth is changes in their emotional state. Over 70 percent of women experience what is commonly referred as the “baby blues” (Centers for Disease Control, 2023), a term used to encompass a range of physical and psychological symptoms that frequently manifest after giving birth. Symptoms including worry, anxiety, tiredness, and sadness can occur within 1 day after giving birth and can last up to two weeks However, for a substantial portion of women, these symptoms endure, leading to a diagnosis of postpartum depression (PPD). The Centers for Disease Control (CDC) reports that approximately 10-15 percent of women are affected by PPD, a noteworthy statistic given its profound impact on both the mother and the child (2023). Furthermore, PPD has an economic impact on society from the added costs of providing care for women and offspring throughout their lives. Luca et al. (2020) estimates the current cost of treating women and their offspring from birth to 5 years postpartum to be around $14 billion. Interventions aimed at reducing the incidence of PPD can have a far-reaching benefits for both mother and child. Preventing PPD can improve the emotional, social, and economic aspects of women and their families. Furthermore, prevention of PPD reduces the economic burden of health systems and enhances overall public health. This purpose of this paper is to provide a framework for a change project aimed at reducing PPD through cognitive behavioral therapy interventions to be implemented at a OB/GYN clinic in the South Florida region. This proposal will include the following: a PICOT question, a literature review, project aims, values, and desired outcomes, conceptual and/or theoretical framework, interventions, and finally recommendations.

3 Proposed Project and PICO(T) Question Problem Identification and Description Although giving birth has a negative psychological impact on many women, it is often mild and transient. In contrast, PPD is a more serious condition both in severity and duration. Currently, PPD is characterized by depressive symptoms that align with the criteria for major depression, with their onset occurring within four weeks of childbirth, as indicated by Moldenhauer (2023).When left untreated PPD has the potential to become disabling and could lead to postpartum psychosis. Although its etiology is unknown, it is thought that changes in hormone levels after childbirth alongside sleep deprivation and prior/familial history of depression play a role (Shuman et al., 2022) . There are also several identified factors which can lead to PPD. Social factors, such as inadequate social support, financial stress, and relationship difficulties, can further exacerbate the risk (Moldenhauer, 2023). Once identified, treatment includes antidepressant drugs alongside psychotherapy. Additionally anxiolytics can be used if anxiety is a major symptom. Although treatments exist, prevention and early identification is key. At medical offices and clinics that provide OB/GYN care to women, the overall strategy is to identify PPD after onset and treat it accordingly (Johnson et al., 2018). Currently there are non-pharmacological interventions that can be implemented and are effective at preventing and reducing PPD. One such intervention is the use of Cognitive Behavioral Therapy (CBT). CBT has been shown to be an effective intervention for PPD and its implementation can be done by nursing professionals (Moldenhauer, 2023). Using proactive methods that focus on prevention is a more sustainable healthcare approach that can lead to positive outcomes for patients.

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4 One barrier to the use of CBT in its current form is its face-to-face or in person delivery mode. For many patients, this modality makes it less than optimal due to time constraints and economic barriers for some (Fonseca et al., 2019). Furthermore, Fonseca et al., argue many clinics and medical offices do not have the infrastructure and resources to implement an in- person CBT delivery model (2019). This project aims to provide an alternative through implementation of CBT through mobile health (mHealth), specifically video conferencing to ameliorate some of the current barriers to implementation. PICO(T) Question In women at risk for postpartum depression, does the implementation of a six-session Cognitive-Behavioral Therapy (CBT) program over Zoom © , compared to standard prenatal care, result in a reduction of postpartum depression symptoms within a 6-week period?  P opulation - women at risk for postpartum depression  I ntervention - six-session Cognitive-Behavioral Therapy (CBT)  C ontrol - standard prenatal care  O utcome - decreased symptoms of postpartum depression  T imeline - 6 weeks Significance of Evidence-Based Project PPD is of high relevance to medical professionals working in clinical settings such as obstetrics and pediatrics where they are most likely to encounter women who are at risk for PPD or suffering from PPD. It is therefore important for them to understand how to prevent, identify and treat these patients. PPD is of clinical importance due to the long-term effects. Even when treated, many women with PPD continue to suffer from depression for years as well as suffering from anxiety

5 disorders (Abdollahi & Zarghami, 2018). Women who suffer from PPD can also exhibit social difficulties, especially in partner relationships with many describing their relationships as cold and distant (Slomian et al., 2019). PPD is not only detrimental for women as it also affects the offspring. Mother to infant bonding is impaired and a depressed mother might not be able to provide a nurturing environment for children to develop. A systematic review by Slomian et al. (2019) discovered that infants of women with PPD exhibited a possibility of compromised motor development, encompassing both gross and fine motor skills. Furthermore, it showed the offspring of women with PPD suffer from behavioral and cognitive deficits well into their adolescent years. This underscores the fact of PPD’s negative and long lasting consequences for both mothers and their children making it necessary to find effective ways to prevent and manage it. Currently, clinicians aim to diagnose and treat PPD after its onset with very few making use of preventive strategies (Johnson et al., 2018) . Using strategies that identify women at risk and prevent the incidence of PPD can greatly improve patient outcomes. Nursing professionals can play a role in the prevention and management of PPD. As direct care providers, nurses often have direct and consistent contact with expectant mothers during the prenatal and postpartum care periods. As such, they are uniquely positioned to identify women at risk for PPD and women who are exhibiting symptoms of PPD. Nurses can provide essential emotional support, education, and resources to mothers, helping them understand the potential risk factors and coping strategies for PPD. Moreover, nurses can facilitate implementation of interventions aimed at preventing and managing PPD. Although mental health interventions have usually been delivered as part of a face-to-face individual or group session, the latest research has shown that “digital therapy,” is an effective

6 means of delivering mental health interventions. Nursing professionals could make use of technology to implement CBT in a more efficient manner. Interventions to prevent PPD have the potential to improve the quality of life of mothers and their children. Women who suffer from PPD have long lasting effects primarily detriment to their mental health. Children of women with PPD also experience mental health issues throughout their lives. In general, PPD places a strain on society through increased costs of caring for these women and their children. At present, there is a recognized need for additional research concerning the efficacy of PPD prevention programs delivered through mHealth platforms (Sun et al., 2019). This project is designed to evaluate the viability of utilizing mHealth for the delivery of evidence-based PPD prevention programs. The outcomes of this project may serve as a roadmap for the expanded adoption of PPD prevention via mHealth, potentially expanding the reach of these interventions to a greater number of women and, in turn, diminishing the occurrence of PPD. Literature Review Symptoms of PPD are the same as those for major depressive disorder with the only differentiating factor being the onset after giving birth. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) defines PPD as a major depressive episode which onset is within 4 weeks of giving birth while The International Classification of Diseases, Tenth Revision (ICD- 10) increases the onset time to 6 weeks. Currently the causes of PPD are unknown but it is thought that changes in hormone levels, and genetics play a role (Shuman et al., 2022). Psychological factors such as history of mental illness, negative attitudes towards the baby as well as risky pregnancies increase the risk of PPD (Mughal, Azhar, & Siddiqui, 2022). Societal factors also play a role with a lack of social support and living in an abusive household being

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7 causative factors. PPD is most common in teenage adolescent females, and low income women have a 50% higher chance of developing PPD when compared to middle-class women (Moldenhauer, 2023). First line treatment of PPD is psychotherapy with the addition of Selective Serotonin Reuptake Inhibitors (SSRIs) when symptoms are moderate to severe (Moldenhauer, 2023). SSRIs and other antidepressants are not always effective and also carry adverse effects making many women, especially those breastfeeding hesitant to take them. Two drugs are currently approved specifically for the treatment of PPD. In 2019, the FDA approved brexanolone injection, which can only be administered at a healthcare facility due to adverse effects such as excessive sedation and loss of consciousness. In August of 2023, the FDA approved zuranolone, a fast acting treatment taken daily for 2 weeks and it is expected to be available at the end of the year (FDA, 2023) Impact of PPD Although the CDC states the incidence of PPD to be around 10-15%, it is thought these statistics are much higher due to many women being undiagnosed. Many women are reluctant to discuss these symptoms and it is thought that around 50% of women go undiagnosed making the percentage of women who suffer from PPD around 20% (Mughal, Azhar, & Siddiqui, 2022). PPD incurs additional costs in the form of medical care, drug costs, and time loss from work. One U.S. study estimates the cost of mood and anxiety disorders in pregnant women including PPD from birth to 5 years postpartum is $14 billion (Luca et al., 2020). Newly released data has shown during the COVID-19 epidemic rates of PPD increased but there it is unknown whether these numbers remain now that the pandemic has officially ended.

8 Even when treated, women who experienced PPD have long lasting effects. Many women suffer from chronic depressive disorder and a minority can develop bipolar disorder, and/or substance abuse (Slomian et al., 2019). Suffering from mental illness leads to negative impacts in daily living and work. It also strains the relationships with family members, friends, and partners eroding the social support system these women need in their lives. PPD affects not just the mother but those around her, especially the newborn as multiple studies have shown these children are also affected throughout their lives. There is a high degree of emotional distance that occurs between a depressed mother and her child which affects the mother-infant bonding leading to insecure attachment in the child (Slomian et al., 2019). It has been shown that children who exhibit insecure attachment patterns suffer from anxiety and have difficulties creating healthy relationships with others. During early childhood, children of mothers with PPD can develop behavioral problems and learning disabilities. The most common problem for these children is language development (Mughal, Azhar, & Siddiqui, 2022). Language development deficiencies impact a child’s performance while in school and into their adult lives. PPD is a condition which effects are long lasting both for the mother and the child, causing a variety of hardships leading to a reduction in quality of life. As such, it is important to screen mothers for PPD and commence treatment as soon as possible. More importantly, an emphasis on prevention rather than treatment could have a meaningful impact for sufferers of PPD. Screening Prevention of PPD involves identifying women at risk. For this effort, screening tools must not only be effective but also easy to use by medical personnel who provide care during

9 pregnancy. Although there are a number of screening methods, their effectiveness varies depending on factors such as the age of the person being screened, and their symptoms (Asgarlou, Arzanlou, & Mohseni, 2021). It is therefore important for healthcare providers to choose a screening tool carefully and choose more than one screening method to identify women at risk or suffering from PPD. Because PPD can manifest both emotionally and physically, screening for both symptoms can increase the ability to identify PPD. Currently the American College of Obstetricians and Gynecologists’ Committee recommends using two screening tools: the Edinburgh Postnatal Depression Scale (EDPDS) and the Patient Health Questionnaire-9 (PHQ-9). The EDPDS screens for psychological symptoms such as anxiety and feelings of sadness while PHQ-9 screen for fatigue, energy loss, and changes in sleep patterns (Asgarlou, Arzanlou, & Mohseni, 2021). Both tools are 10 item questionnaires that can be done quickly during office visits. Their effectiveness and ease of use make them appropriate tools in the medical office/clinic where time available for each patient is usually compromised. Prevention Interpersonal psychotherapy, SSRIs, and cognitive behavioral therapy (CBT) have been found effective in the prevention of PPD. Out of the three, CBT has been shown to be most effective (Sun et al., 2019). CBT teaches patients to identify and challenge dysfunctional thoughts and behaviors (Moldenhauer, 2023). The fact that CBT teaches a patient how to deal with their emotions gives them tools they can use in the future making it a valuable tool for healthcare professionals as patients learn self-regulatory skills that could be of help in future pregnancies and/or transferred to other problems in their daily lives. One program that is effective in preventing PPD is the ROSE (Reach Out, Stay Strong, Essentials for new mothers). This evidence based program consists of four group sessions where

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10 women are taught about social support, relaxation techniques, psychoeducation on relationships, assertiveness, communication, and goal setting. A fifth individual session reviews symptoms of depression and identifies individual problems. Randomized clinical trials (RCTs) have shown ROSE to decrease rates of PPD by up to 50% (Johnson et al., 2018). This program is relatively easy to implement and it can be delivered by many professionals in the clinical setting including nursing professionals and medical assistants. This makes ROSE a valuable tool for providers who might not have access to an onsite therapist. Although CBT has been proven to be effective, a face-to-face delivery creates barriers both for the patient and the provider making it less than optimal for many. For the provider, a face-to-face CBT model might be difficult to implement due to a lack of time and/or employees trained to deliver it (Fonseca et al., 2019). In the U.S., providers often care for many patients leaving them with very little time to implement CBT. Additionally, nursing professionals are also task with many responsibilities in their day-to-day schedule making the delivery of CBT difficult. A simple solution would be to hire a team to implement CBT but that might not be financially feasible for most providers. On the patient’s part, barriers in accessing face-to-face CBT are other responsibilities such as family and work making it hard to attend scheduled sessions. There is also an economic component with many women not being able to afford insurance copays. Low income women are at highest risk for PPD yet they have the lowest rates of attendance to CBT programs when available (Johnson et al., 2018). The stigma around PPD and mental illness in general creates another difficult barrier as some women might be unwilling to attend sessions due to cultural beliefs and the societal expectation of motherhood as the happiest time in a woman’s life.

11 Over the last few years there has been a focus on delivering medical services using technology. The COVID-19 pandemic has only accelerated the delivery of healthcare services over phone apps, video conferencing, and texts. Mobile health (mHealth) has been successfully used to deliver a variety of healthcare services and many insurance companies currently offer mHealth as a cheaper alternative for doctor visits. mHealth is proven effective in the delivery of mental health visits and therapy (Fonseca et al., 2019). mHealth could be an effective strategy in overcoming the barriers that often lead to low compliance in face-to-face CBT. mHealth provides a flexible, convenient, and private option for women who might otherwise be unable to take part. mHealth for PPD – Knowledge Gaps Although CBT aimed at preventing PPD could be effectively delivered over mHealth, there is no concrete evidence that it is a viable alternative. It is generally assumed that because mHealth based CBT is effective for other mental health conditions, then it can be used for PPD prevention. Although there are some studies that have shown that CBT delivered over other means besides a face-to-face setting there is not enough evidence to fully support it. Sun et al., (2019) argued clinical effectiveness of using mHealth to deliver CBT must be better evaluated through RCTs. Further research into this method is required to assess the effectiveness of alternative delivery of CBT in improving and preventing PPD in women. Validating this approach could help to care for a larger number of women who might otherwise not be willing to participate or who do not have the means due to financial instability or living in areas where prenatal care is limited. Nursing professionals are able to partake in this research and help to develop effective alternatives to improve patient outcomes.

12 PPD is a significant concern with far-reaching consequences for mothers, children, and society. Preventive strategies, such as effective screening and the use of interventions like CBT and innovative approaches like mHealth, hold promise in mitigating its impact. Nursing professionals play a crucial role in researching and implementing these strategies, ultimately improving patient outcomes and the overall quality of life for women facing PPD. Project Aims, Values, and Desired Outcomes This project aims to overcome barriers in delivering CBT for PPD by utilizing video conferencing. The focus is on accessibility, especially for high-risk groups and offering a low- cost tool for providers. The initiative seeks to assess the effectiveness of CBT over Zoom©, contributing to knowledge on mHealth interventions. It also aims to collect participant feedback to refine the intervention. The project values reducing PPD rates and facilitating women's participation in CBT to diminish the risk for developing PPD. Project Aims Despite the fact that CBT has been proven effective in the treatment of PPD, barriers to delivery exist for both healthcare providers and patients. Sun et al.(2019), found many healthcare professionals lack the resources to deliver face-to-face CBT due to the time constraints. For patients, day-to-day responsibilities might cause them to miss CBT sessions diminishing the effects of these interventions. This is most evident for high risk patients like low income women and teenage mothers who could benefit the most but have the lowest rates of completion (Johnson et al., 2018). This project aims to ameliorate these barriers through implementation of CBT over a video conferencing setting making it more accessible to women. Although the use of this technology, often termed mHealth, has been shown to be effective in delivering a variety of mental health interventions, its effect on the prevention of

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13 PPD has not been fully established. Current data is promising but further studies are needed to validate the clinical effectiveness of alternative methods of delivering CBT (Zhou et al., 2020). Another aim of this change project is to assess the viability and effectiveness of delivering CBT over Zoom©. This project aims to add to the current body of knowledge regarding the use of mHealth, specifically video conferencing in increasing participation in CBT and decreasing rates of PPD. This project also aims to collect subjective information from participants to improve future CBT sessions. Because this project will take place over video conferencing means it could be delivered by one or two individuals and being only a six session intervention, it should not require long hours to complete. Many CBT programs for PPD prevention and treatment offer free training and materials making them easy to implement from an economic standpoint. For this project, major expected expenses are IBM SPSS statistics program and a paid Zoom subscription to conduct video conferencing. Benefits of this project is the availability of CBT for women whom might otherwise not be able to attend face-to-face sessions. For providers and health clinics, this project could provide a low cost intervention for decreasing PPD. Values The main value for this project is using CBT to decrease the rates of PPD by teaching women skills to deal with the physical and mental demands of pregnancy. Another value for the project is to facilitate the participation of women in CBT sessions. As previously discussed, some women find it difficult to attend face-to-face sessions and providing them with an alternative that works around their personal lives can increase the number of women who participate. Participating in CBT for PPD has the added effect of teaching women strategies they can apply to other problems in their lives and gives them tools to deal with stress in future

14 pregnancies further preventing the incidence of PPD. For practitioners, the value of this project is the ability to improve the health of mothers and their children by improving their care to prevent incidence of PPD. Desired Outcomes One desired outcome is collecting valid data to compare the effectiveness of CBT delivered over Zoom ® when compared to standard care. A long-term desired outcome is to give healthcare providers a low cost, easy tool for improving outcomes for pregnant women and their children. If CBT over Zoom ® is shown to be effective, it is expected that healthcare providers would be willing to use it resulting in positive results for patients. Another desired outcome is to collect subjective data on the intervention from the participants’ perspective that can be used to further refine and improve CBT over Zoom ® . It is expected that this data will allow for further improvements that can increase the effectiveness of CBT delivered over Zoom ® . Data collected through a six-point numerical Likert scale will provide investigators insight into participants’ thoughts on the delivery method and negative aspects of the intervention. A six-point numerical Likert scale provides data that is easier to analyze and it encourages more careful consideration to each question by the participants (Taherdoost, 2019) Theoretical/Conceptual Framework This project addresses the multifactorial nature of postpartum depression (PPD) by adopting a psychosocial perspective, emphasizing the interplay of biological, psychological, and environmental factors. Acknowledging that psychological vulnerabilities, life stressors, and inadequate social support elevate the risk of PPD, the project focuses on preventive strategies through cognitive and behavioral modifications.

15 Identification of Framework PPD is a multifactorial condition that includes biological, psychological and environmental/social factors. Psychological vulnerabilities as well as life stressors and a lack of social support systems place women at higher risk for PPD (Mughai et al., 2022). This project focuses on a psychosocial perspective to prevent PPD. It recognizes that addressing these vulnerabilities through cognitive and behavioral modifications can enhance the well-being of women and prevent PPD. Two theories serve as an underpinning for this project: Neuman’s Systems Model and Orem’s Self-Care Deficit Theory . These two theories help to define PPD through a psychosocial perspective and they explain how personal thoughts and emotions as well as social and environmental factors place people at risk for negative health outcomes. More importantly, these theories provide a framework for nursing interventions aimed at addressing the psychosocial component of PPD. Assumptions of the Framework Orem’s Self-Care Deficit Theory is based on a patient’s ability to engage in self-care. Self-care is defined as the activities that a person performs on their own behalf to maintain their health and well-being (Gonzalo, 2023). Another assumption of Orem’s theory is that individuals have various degrees of self-care agency and when individuals are not able to engage in self- care, a self-care deficit occurs. When these self-care deficits occur, then nursing interventions are required to not only assist with self-care activities but to also promote self-care agency (Gonzalo, 2023). Key components of Orem’s theory are assessment, interventions, and monitoring with the aim of empowering patients to engage in long-term self-care practices. Women who suffer from PPD have psychosocial and environmental factors that can prevent them from engaging in self-

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16 care activities placing them at risk for PPD. Orem’s theory emphasizes the role of the nurse in delivering patient education and counseling to improve confidence in the patient’s ability to engage in self-care and improve their wellbeing. The Neuman System Model (NSM) emphasizes stress factors that can deteriorate a person’s health and well-being. Neuman’s theory assumes a patient is an open system that responds to stressors in its environment with physiological, psychological, sociocultural, developmental, and spiritual factors influencing this response (Hannoodee, & Dhamoon, 2023). Neuman’s theory assumes people create a series of defenses to protect against stressors but these defense lines are sometimes penetrated by stressors affecting health and wellbeing. Neuman’s theory emphasizes nursing interventions (primary, secondary, and tertiary) that enhance patient healing though stress management and elimination (Hannoodee, & Dhamoon, 2023). Within the context of PPD prevention, the NSM’s emphasis on treating stressors serves as a basis for developing interventions that ameliorate the effect of the social and environmental factors that affect women and increase the risk for PPD. Element of Phenomenon For this change project, Orem’s theory applies through the implementation of self-care education for soon to be mothers. CBT interventions planned for this project involve teaching patients about self-care activities for managing stress. Additionally this project aims to empower patients through improvement of their self-care agency by teaching them to recognize and manage negative thought patterns and develop problem-solving skills. Orem’s theory provides a framework for nursing professionals to deliver CBT and improve patients’ abilities to engage in self-care.

17 Within the context of PPD, the NSM’s primary intervention strategy is prevention through education. This project makes use of this principle by aiming to reduce the risk of PPD through teaching individuals resilience skills and effective coping mechanisms. Neuman’s theory emphasizes stress management and elimination which is a key component of this project. This project involves teaching patients about the importance of social support in preventing PPD which is one of the variables identified by NSM as a key defensive barrier to stressors. A core component of the NSM is strengthening the variables/lines of defense an individual has. Through the use of CBT, this project aims to improve the psychological and sociocultural defenses of pregnant women to decrease the incidence of PPD. Discussion of Pertinent Research For many women, pregnancy is a time of not just physical changes, but mental changes that can cause stress. There are also social and economic factors that can add stress during pregnancy increasing the risk of PPD. Orem’s Self-Care Deficit theory was chosen for this project because it provides a valuable framework from which to address self-care needs and self- care agency in pregnant women. During pregnancy, women might often neglect self-care, placing them at a higher risk for PPD (Can et al., 2019). Improving the ability to engage in self- care during pregnancy can improve the capacity of women to deal with common stressors, especially ones that might be out of their control such as social and environmental stressors. Orem’s theory has been used successfully in the treatment of other diseases and studies have also shown it can be effective in designing interventions for PPD (Can et al., 2019). The emphasis of the NSM on creating barriers against stressors made it a valuable theory in the development of this project. Women at risk for PPD are exposed to many stressors making the NSM concept of restructuring cognitive patterns through education valuable. This project

18 makes use of primary and secondary interventions from the NSM to give pregnant women the tools to deal with the added stressors of pregnancy. The NSM has been effective as a framework for effective interventions to treat major depressive disorder (Basogul, & Buldukoglu, 2020). Studies have also shown that psychoeducation based on the NSM can be successfully implemented through a CBT program (Hannoodee, & Dhamoon, 2023) . The integration of both theories offers a valuable approach to preventing PPD. Orem's self-care education and agency development, are crucial for managing stress during pregnancy. Simultaneously, the NSM's focus on stress management, cognitive pattern restructuring, and defense enhancement aligns with this project's goal of equipping women to cope with pregnancy- related stressors and decrease the risk for PPD. Intervention for Proposed Clinical Change Project This section will outline the proposed solutions and interventions designed to address the identified challenges. It will detail the participant selection criteria and sampling population, providing insight into the targeted demographic. The setting for the interventions will be described, along with the methods employed for data collection and analysis. The section will also acknowledge any limitations inherent in the approach and identify gaps in understanding that may impact the outcomes of the change project. Proposed Solutions and Interventions This project will use an established PPD prevention program: Reach Out, Stay Strong, Essentials for mothers of newborns (ROSE). The ROSE program is an evidence-based intervention (EBP) which was chosen for both its effectiveness at preventing PPD and its ease of use. Results from randomized clinical trials have indicated that the ROSE program can reduce Postpartum Depression (PPD) rates by as much as 50% (Johnson et al., 2018). ROSE is highly

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19 scripted, making it easy to deliver by a large number of interventionists of varying qualifications. ROSE is not only effective at preventing the incidence of PPD but also at preventing PPD postpartum for up to six months (Zlotnick et al., 2016). The evidence-based program comprises four group sessions, during which women receive instruction on various topics such as social support, relaxation techniques, psychoeducation related to relationships, assertiveness, communication skills, and goal setting. Additionally, a fifth individual session is dedicated to reviewing symptoms of depression and addressing individual concerns. This study will deliver the ROSE program as per its guidelines with the only change being delivery over Zoom ® video conferencing. All materials for the ROSE implementation will be downloaded at the Women and Infants Hospital of Rhode Island’s website ( https://tinyurl.com/26abwkjf ). This includes PowerPoint presentations, patient’s workbook, and educator guide. Patients that qualify and consent to participate in study will be given all materials during OB/GYN visit. Intervention will consist of 4 weekly sessions lasting 90 minutes and a fifth session delivered postpartum. Although a fifth session will be delivered as per the program guidelines, data will be collected before its delivery. The decision was made due to time constraints for the study’s timeline for completion. Waiting for all study participants to give birth is not possible at this time but the final session will be delivered nonetheless to guarantee participants receive ROSE in its entirety. First Session – Psychoeducation on PPD The first session is comprised of introductions and the interventionist setting up ground rules for the group and explaining rationale for the program. The remaining time will be used to

20 educate group on baby blues and PPD with group discussions on society’s expectations of motherhood versus the realities of being a mother in addition to the etiology and symptoms of PPD. Session will close with a discussion on the importance of support from others. Second Session – Relaxation Strategies / Support The second session will teach women how to do breathing exercises to relax as well as progressive muscle relaxation techniques which they will be asked to practice daily as part of homework for the following session. Transition to motherhood will be discussed alongside positive and negative aspects of being a new mother. The group will receive education on how to manage the negative aspects of motherhood and how to access and develop support during the prenatal and postnatal period. Third Session – Interpersonal Conflicts Group will learn the importance of healthy relationships and the ways a baby can place a strain on their current relationship. The group will learn and discuss ways to navigate disputes and the importance of assertiveness in maintaining healthy relationships. This session will rely heavily on role play scenarios and there will be an emphasis on recognizing and removing themselves from abusive relationships. Fourth Session – Goal Setting / Planning Group will review the importance of assertiveness and discuss barriers as well as learn techniques for being assertive. The group will discuss the importance of setting goals and planning for the future. Like the third session, the group will engage in role play to practice skills. The session will close with a review of the previous sessions.

21 Fifth Session – Postpartum Individual Session Review of the previous sessions with discussion on individual difficulties experienced since the last session and after giving birth. Participant Selection Criteria/Sampling Population Participants will include 16 pregnant women in their second trimester of pregnancy who are at risk for developing PPD. It is recommended ROSE is completed before 36 weeks of pregnancy (Sun et al., 2019) which is the reason the second trimester was chosen. There is no age range for this study and participants who meet criteria will be randomly selected and placed into two groups to receive either the planned intervention or standard OB/GYN care. Criteria for study admission will be: (a) pregnant women in second trimester of pregnancy, (b) identified risk for PPD, (c) ownership or ability to procure computer/smartphone to participate in intervention, (d) English speaker. Setting The proposed setting for this program is a large obstetrics and gynecology (OB/GYN) practice in Miami-Dade County, FL with an additional location in Broward County, FL. The clinic provides a variety of services to women in the South Florida region including infertility treatment, adolescent OB/GYN, and telemedicine. Currently, the clinic staffs five physicians and a Certified Nurse Midwife (CNM). As previously stated, young mothers are at a higher risk for PPD. The fact this clinic sees a large number of patients and provides specific services for teenagers makes it valuable for this project. Additionally, the clinic already offers telehealth services and the CNM is trained in the ROSE program which facilitates intervention delivery.

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22 Pre/Post Data Collection Presently, the American College of Obstetricians and Gynecologists’ Committee recommends the utilization of two screening instruments: the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire-9 (PHQ-9). The EPDS is designed to assess psychological symptoms like anxiety and feelings of sadness, whereas the PHQ-9 focuses on fatigue, energy loss, and changes in sleep patterns (Asgarlou et al., 2021). Both questionnaires consist of 10 items, allowing for quick completion during routine office visits. These tools were chosen due to their ease of use and ability to identify PPD. Both scales are accurate, effective, and have a high degree of sensitivity in identifying PPD (Park & Kim, 2023). Their effectiveness and user-friendliness make them well-suited for use in medical offices and clinics, where the available time for each patient is often limited. Women who are potentially susceptible to Postpartum Depression (PPD) will be screened using both scales. To be eligible for participation in the study, a woman must obtain a score exceeding 9 on the EPDS and/or a score surpassing 10 on the PHQ-9. Women who receive a positive score on question 10 of the EPDS, which evaluates the risk of suicidality, will be immediately referred to a physician in the clinic and/or mental health services in accordance with the guidelines outlined in the EPDS. Additionally subjective data on participants’ views and opinions on intervention will be collected through the use of a numerical Likert scale. The aim of this data is to assess strengths and weaknesses of intervention to aid in improvements to future implementations. Study Results This study uses a controlled trial design to measure the effect of the intervention. The baseline data will be established using the initial assessments of EPDS and PHQ-9.

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23 Subsequently, these assessment scales will be administered to the participants once more, specifically two weeks after the final intervention session. A comparative analysis will then be conducted between the initial scores and the post-intervention scores to evaluate the impact of the intervention on PPD and to make comparisons with standard care. Statistical analysis will be made using IBM ® SPSS ® Statistics software. Limitations The sample's inclusion criteria, specifically requiring ownership or access to a computer/smartphone, may introduce selection bias, limiting the generalizability of findings to those with digital access. To address potential participation issues, strategies such as providing necessary technology or conducting sessions at convenient times will be explored to enhance accessibility and encourage engagement. Practical constraints, such as time sensitivity due to pregnancy timelines, may affect the depth of data collected. To control these limitations, efforts will be made to maximize data quality within the available timeframe, emphasizing thorough pre-session assessments and post- intervention evaluations. Gaps in Understanding Although CBT aimed at preventing PPD could be effectively delivered over mHealth, there is no concrete evidence that it is a viable alternative. It is generally assumed that because mHealth based CBT is effective for other mental health conditions, then it can be used for PPD prevention (Fonseca et al., 2019). Although there are some studies that have shown that CBT delivered over other means besides a face-to-face setting there is not enough evidence to fully support it. Sun et al., (2019) argued clinical effectiveness of using mHealth to deliver CBT must be better evaluated through randomized controlled trials.

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24 Further research into this method is required to assess the effectiveness of alternative delivery of CBT in improving and preventing PPD in women. Validating this approach could help to care for a larger number of women who might otherwise not be willing to participate or who do not have the means due to financial instability or living in areas where prenatal care is limited. Nursing professionals are able to partake in this research and help to develop effective alternatives to improve patient outcomes. Recommendations and Conclusions It is important to place an emphasis on prevention of PPD and implement programs aimed at prevention alongside treatment. One of the best interventions for PPD is cognitive behavior therapy (CBT) but it requires individual or group counseling. Economic and social barriers can prevent women from attending these programs ( Darcy et al., 2022). Delivering CBT over video conferencing can increase access to CBT since patients do not need to go the office/clinic to receive these interventions. Nursing professionals provide direct care to women giving them a great opportunity to implement these preventive strategies over video conferencing and help to decrease the incidence of PPD. This change project was based on the following PICOT question : In women at risk for postpartum depression, does the implementation of a six-session Cognitive-Behavioral Therapy (CBT) program over Zoom © , compared to standard prenatal care, result in a reduction of postpartum depression symptoms within a 6-week period? For this project, the Reach Out, Stay Strong, Essentials for mothers of newborns (ROSE) program will be delivered to pregnant women over Zoom and compared to standard prenatal care to assess the effectiveness in preventing PPD.

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25 Proposed Recommendations One proposed recommendation for this project is the widespread use of preventive strategies aimed at reducing PPD. Currently, the emphasis of clinicians in regards to PPD is identification and treatment after onset as opposed to preventive strategies (Johnson et al., 2018). One key issue with this strategy is that not every woman that suffers from PPD will seek treatment. Research shows low-income women suffer from PPD at higher rated but they are less likely to seek help and receive treatment (Darcy et al., 2022). For women at higher risk for PPD, preventive strategies can help to not only prevent PPD but also help to quickly identify these patients and make sure they receive adequate care in the prenatal and postnatal period. This project also recommends the use of mobile health (mHealth) to deliver CBT based PPD prevention programs with the aim of improving the number of women who participate. Although CBT is an effective evidence based intervention for PPD prevention, there are roadblocks to implementation. The traditional method of delivering CBT in a clinical setting might prevent some women from participating due to a lack of time and/or transportation (Fonseca et al., 2019). The use of mHealth, specifically video conferencing can decrease these barriers and improve adherence rates to these programs. This project recommends using ROSE as the CBT based preventive program of choice. Other programs require interventions to be delivered by mental health clinicians (Johnson et al., 2018) creating a roadblock to most medical offices and clinics providing OB/GYB services. ROSE is highly scripted, flexible, and does not need a mental health clinician. Studies have demonstrated ROSE can be effectively delivered by nursing professionals and medical assistants (O’Connor et al., 2019). Overall, this change project recommends the following strategies to decrease rates of PPD in women:

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26  Widespread use of CBT based preventive interventions aimed at reducing PPD rates by OB/GYN clinics  Delivery over video conferencing to improve adherence rates  Using ROSE as the intervention of choice Limitations of Study For this project, the lack of experience with the ROSE program is a limiting factor; Although the program can be delivered by nursing professionals and medical assistants, the persons charged with delivery must be trained in the program and professionals delivering the program for the first time could decrease the program’s effectiveness. Additionally the medical professionals responsible for implementing the program over Zoom ® must be proficient in using the video conferencing program and most of its features. Delivery over Zoom ® is dependent on proper computer equipment and/or smartphones alongside fast internet connections. Participation in every session could be hindered by lack of equipment or slow internet connections. This could affect the outcomes of the study and must be taken into consideration. Participants must also be proficient in using Zoom ® to fully participate. Another limitation are participants’ opinions on participating over Zoom ® . User engagement and participation can be affected by participants concerns about safety and privacy (Koh et al., 2022). Participants could have concerns about participating in the program if they believe other people might be listening or viewing their sessions impacting attrition rates. Privacy concerns can also limit the delivery of ROSE over Zoom ® as professionals in charge of delivery must be cognizant of privacy concerns. The need to guarantee patient privacy limits accessibility and flexibility due to participants not being able to participate from anywhere

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27 they might desire as public spaces and the presence of others could breach confidentiality for other participants. Summary of Research Orem’s Sel-Care Deficit Theory and the Neuman System Model (NSM) were the theoretical frameworks for the development of this study. These theories emphasize the need for ameliorating the effect of stressors and the need to improve self-care agency patients. For women at risk for PPD, there are multiple factors involved, including societal/environmental factors. Women who are at risk for PPD often lack the coping strategies and support to manage the emotional and physical stress of pregnancy (Moldenhauer, 2023). Interventions aimed at preventing PPD must address self-care needs and self-care agency to manage with stressors. CBT has been found to be highly effective in preventing PPD when compared to pharmacological treatments and interpersonal therapy (Sun et al., 2019). Although there is some evidence the delivery of mental health interventions over mHealth are effective, there is a lack of evidence whether they are as equally effective as in- person delivery. Sun et al. (2019) recommends further research is needed to evaluate CBT over mHealth as a viable alternative. This research study aims to add to the current body of knowledge by assessing the effectiveness of CBT delivery over video conferencing. The results of this study can further guide interventions at the local/clinical level and help to create effective and easy to implement strategies that can improve patient outcomes. Results can provide further evidence of the effectiveness of mHealth based CBT implementation and help to create guidelines that stress prevention alongside treatment of PPD. The study compares ROSE delivery over Zoom ® to standard care. Further studies should assess the effectiveness of the ROSE program delivered over video conferencing to the in-person delivery.

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28 Conclusion Implementing interventions to prevent postpartum depression (PPD) holds the potential to enhance the well-being of mothers and their children. Women grappling with PPD often face enduring adverse effects, particularly on their mental health. Furthermore, offspring of mothers experiencing PPD may encounter mental health challenges throughout their lifetimes. Overall, the societal impact of PPD is notable, contributing to heightened costs associated with the care of affected women and their children. Currently, there is a recognized imperative for additional research on the effectiveness of PPD prevention programs delivered through mobile health (mHealth) platforms (Sun et al., 2019). This project is specifically crafted to assess the feasibility of utilizing mHealth for delivering evidence-based PPD prevention programs. The findings of this project have the potential to offer guidance for the broader integration of PPD prevention via mHealth, thereby extending the reach of these interventions to a larger population of women and, consequently, reducing the occurrence of PPD .

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29 References Abdollahi, F., & Zarghami, M. (2018). Effect of postpartum depression on women’s mental and physical health four years after childbirth. East Mediterranean Health J , 24 (10), 1002-9. Asgarlou, Z., Arzanlou, M., & Mohseni, M. (2021). The importance of screening in prevention of postpartum depression. Iranian Journal of Public Health . https://doi.org/10.18502/ijph.v50i5.6127 Basogul, C., & Buldukoglu, K. (2020). Neuman systems model with depressed patients: A randomized controlled trial. Nursing Science Quarterly, 33 (2), 148–158. https://doi.org/10.1177/0894318419898172 Can, O. H., Baykal Mese, Z., Kocak, C. Y., Ocalan, D., Dal Alp, N., & Sevil, U. (2019). Factors affecting perceived stress and self-care agency pregnant women. Journal of Health, Medicine and Nursing , 59 , 46-54. Centers for Disease Control and Prevention (CDC). (2023). Depression during and after pregnancy . Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/features/maternaldepression/index.html Darcy, A., Beaudette, A., Chiauzzi, E., Daniels, J., Goodwin, K., Mariano, T. Y., Wicks, P., & Robinson, A. (2023). Anatomy of a woebot® (WB001): Agent guided CBT for women with postpartum depression. Expert Review of Medical Devices, 20 (12), 1035–1049. https://doi.org/10.1080/17434440.2023.2280686 Fonseca, A., Alves, S., Monteiro, F., Gorayeb, R., & Canavarro, M. C. (2019). Be a mom, a web based intervention to prevent postpartum depression: Results from a pilot randomized controlled trial. Behavior Therapy, 51 (4), 616–633.

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30 https://doi.org/10.1016/j.beth.2019.09.007 Gonzalo, A. (2023). Dorothea Orem: Self- Care Deficit theory . Nurseslabs. https://nurseslabs.com/dorothea-orems-self-care-theory/ Hannoodee, S., & Dhamoon, A. (2023). Nursing Neuman Systems Model . https://www.ncbi.nlm.nih.gov/books/NBK560658/ Johnson, J., Wiltsey-Stirman, S., Sikorskii, A., Miller, T., King, A., Blume, J., Pham, X., Moore Simas, T., Poleshuck, E., Weinberg, R., & Zlotnick, C. (2018). Protocol for the Rose Sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women. Implementation Science , 13 (1). https://doi.org/10.1186/s13012-018-0807-9 Koh, J., Tng, G. Y., & Hartanto, A. (2022). Potential and pitfalls of Mobile Mental Health Apps in traditional treatment: An umbrella review. Journal of Personalized Medicine , 12 (9), 1376. https://doi.org/10.3390/jpm12091376 Luca, D. L., Margiotta, C., Staatz, C., Garlow, E., Christensen, A., & Zivin, K. (2020). Financial toll of untreated perinatal mood and anxiety disorders among 2017 births in the United States. American Journal of Public Health , 110 (6), 888–896. https://doi.org/10.2105/AJPH.2020.305619 Moldenhauer, J. (2022, August). Postpartum depression . Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/postpartum- care-and-associated-disorders/postpartum-depression?query=postpartum+depression Mughai, S., Azhar, Y., & Siddiqui, W. (2022). Postpartum depression - statpearls – NCBI

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31 Bookshelf . National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK519070/ O’Connor, E., Senger, C. A., Henninger, M. L., Coppola, E., & Gaynes, B. N. (2019). Interventions to prevent perinatal depression. JAMA, 321 (6), 588. https://doi.org/10.1001/jama.2018.20865 Park, S. H., & Kim, J. I. (2023). Predictive validity of the Edinburgh postnatal depression scale and other tools for screening depression in pregnant and postpartum women: a systematic review and meta-analysis. Archives of Gynecology and Obstetrics , 307 (5), 1331-1345. Slomian, J., Honvo, G., Emonts, P., Reginster, J. Y., & Bruyère, O. (2019). Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women's Health (London, England) , 15 , 1745506519844044. https://doi.org/10.1177/1745506519844044 Sun, M., Tang, S., Chen, J., Li, Y., Bai, W., Plummer, V., Lam, L., Qin, C., & Cross, W. (2019). A study protocol of mobile phone app-based cognitive behaviour training for the prevention of postpartum depression among high-risk mothers. BMC Public Health , 19 (1). https://doi.org/10.1186/s12889-019-6941-8 Taherdoost, H. (2019). What is the best response scale for survey and questionnaire design; review of different lengths of rating scale/attitude scale/Likert scale. Hamed Taherdoost , 1-10. Zhou, C., Hu, H., Wang, C., Zhu, Z., Feng, G., Xue, J., & Yang, Z. (2020). The effectiveness of mHealth interventions on postpartum depression: A systematic review and meta-analysis. Journal of Telemedicine and Telecare , 28 (2), 83–95. https://doi.org/10.1177/1357633x20917816

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32 Zlotnick, C., Tzilos, G., Miller, I., Seifer, R., & Stout, R. (2016). Randomized controlled trial to prevent postpartum depression in mothers on public assistance. Journal of Affective Disorders , 189 , 263–268. https://doi.org/10.1016/j.jad.2015.09.059

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