Discussion of Results of EPND programme.

The low first scores in Group One may be a true reflection of the woman's feelings; alternatively they could be attributed to an initial reluctance to reveal feelings to the Health Visitor for fear of recriminations, ie being labeled an 'unfit mother.' Then, as the relationship between mother and Health Visitor becomes stronger and trust is established, a more accurate indication of the mother's feelings may be recorded on the second screening.

More women declined the offer of Health Visitor support visits in the first group than in any other, possibly due to the fact that only one of the six to refuse was found to be depressed when using the Edinburgh score. The remaining five had 'borderline' scores and appeared to perceive themselves as 'stressed' rather than depressed.

This theory is borne out in the second group, where there was only a 50% uptake of Health Visitor support visits from women with 'borderline' scores. Of the women with scores indicative of depression, however, there was a 90% uptake of support visits.

As we had anticipated, all 16 women in Group Three had Health Visitor support. Interestingly, of the three women with both scores indicative of depression, only one had any additional treatment, being prescribed anti-depressants. All but one of the remaining thirteen women had a combination of Health Visitor support visits and anti-depressant therapy/referral to other agencies (see breakdown.)

This pattern is repeated in the fourth group, with 100% uptake of Health Visitor support visits and over half of the women receiving a combination of treatment approaches.

Analysis of the distribution of treatment options within these groups seems to support our theory that the greater the depression/anxiety felt by each woman, the higher the uptake of Health Visitor support and allied services. Initial examination of the statistics seems to indicate that most Health Visiting support goes into meeting the needs of the depressed population, but in the groups where both scores are raised it is apparent that women with 'borderline' scores also have a high level of input from Health Visitors when they request it.

The groups with two raised scores best demonstrate the Health Visitors use of multi-agency referrals as they and their clients thought appropriate. Interestingly, the rate of onward referral can be seen to increase according to the severity of the symptoms (identified by the level of elevation of the score.)

It has long been known that women with post-natal depression demonstrate a marked improvement of their symptoms after receiving non-directive counselling from their Health Visitors (Holden,1990). More recent research by Appleby (1997) found that post-natally depressed women were equally helped by anti-depressant therapy and counselling. While Appleby found no extra benefit from having both treatments simultaneously, his findings allow health professionals a choice of effective treatment options which can be geared to individual needs.

Examples of such tailoring of treatment options to suit individual need can be seen throughout the raw data compiled for this report. Anecdotal evidence obtained during data collection established that for many women, anti-depressant therapy is still not socially acceptable; while two women declined increased Health Visitor support but saw their GP for anti-depressant therapy.

We recognise that Health Visiting input alone was not sufficient or appropriate in a number of cases of post-natal depression we uncovered, and believe that our statistical summary demonstrates this awareness of the limitations of non-directive counselling for some clients. Our role in such cases then evolved to that of advocate for individual women, facilitating access to other health professionals and agencies in order to obtain the optimum level of support each client individually felt she wanted and/or needed. However, one criteria for immediate liaison with the GP which has a positive response to the question on self-harm - this occurred with twelve women (18% of the depressed population.) This figure seems alarmingly high to us, but we have unfortunately been unable to find any data to use as a comparison.

On introducing the Edinburgh Post-natal Depression Score in our area, we found that Health Visitor support visits alone can help in a high proportion of cases. Our practice population is based in an area of recognised deprivation, having the highest Townsend Deprivation Score of any practice in Cardiff (Bro Taf Cardiff Health Profile Information Update 1999.) This statistic is mirrored in our high prevalence of post-natal depression (21%). In our experience many of the problems identified as potential triggers for post-natal depression are found in our practice population. These include the absence of a confidante (Campbell et al, 1983); a poor relationship between the woman and her own mother (Holden, 1990); and the condition of 'learned helplessness' (Seligman, 1975), where women feel they have little control of the social factors such as high unemployment, lack of finances and poor housing, that impinge on many of their lives.

Indeed, our data appears to uphold the theory that women with poor social support networks are those most likely to need Health Visiting intervention when being identified as post-natally depressed or having a 'borderline' raised score. Most of the women who declined extra Health Visitor support visits cited already having a good network of support or a return to work as the reason.