NR 606 Week 2 Discussion Preparing the Discussion
Dr. Zimmerman and classmates;
Natalie is a 32-year-old who gave birth to a healthy baby girl 12 weeks ago. Two years ago, she had a
stillborn son. Natalie was initially very excited about the birth of her baby and thrilled to receive
attention from extended family and friends. Over the past two weeks, she has become withdrawn,
anxious, and feeling very guilty about the fact that this baby survived when her son did not. She has
continued to breastfeed but feels “disconnected” from the baby. Natalie’s only contact with health
care providers since delivery has been her obstetrician for a 6-week follow-up and her daughter’s
pediatrician for the 1-month and 2-month well-baby visits. Natalie’s mental health was not addressed
at either visit. She has sought care with the psychiatric mental health nurse practitioner (PMHNP)
because she is concerned about her mental health. Natalie has no history of a mental health diagnosis
and is anxious about the stigma of seeking treatment for her low mood, especially since her mother-
in-law told her that she should have “bounced back” by now.
o Identify the appropriate screening tool for Natalie to complete during her first visit and
discuss why the selected tool is appropriate for the client.
The recommended screening tool for Natalie would be the Edinburgh Postnatal Depression Scale
(EPDS). A highly respected, reliable tool (Mastrangelo, 2022). This recommendation is endorsed by the
American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics
(AAP), and the American Academy of Family Medicine (AAFP). The EPDS includes screenings for drug
and alcohol history, smoking habits, and all prescription and over-the-counter drug medications. This
screening is a 10-item self-administered questionnaire that only takes a few minutes. Scoring 13 or
greater indicates a risk of developing depression, and further assessments need to be done to evaluate
the patient (Carlson et al., 2024).
The American College of Obstetricians and Gynecologists (ACOG) recommends at least one screening
during perinatal visits; the patients should be monitored for changes or increased symptom
presentation (Carlson et al., 2024). The ACOG further states that this screening process should be
continued throughout pregnancy, personalized to each patient’s needs. Best practice guidelines support
additional screening postpartum check-in at three weeks and no more than 12 weeks post-partum
(Ellington, 2021). Strengthening the recommendation for screening, the U.S. Preventive Services Task
Force recommends screening new mothers at well-baby checkups 1, 2, 4, and 6 months using the EPDS
(Mastrangelo, 2022).
Unfortunately, Natalie is 12 weeks post-partum, and over the past two weeks, she has developed these
symptoms. I would have thought that with the history of a stillborn, a significant risk factor, she would
have been under the radar of her caregivers and family to be susceptible to the occurrence of a
depressive episode. According to Carson et al. (2024), although she is more than four weeks postpartum
the two weeks of, a minimum of 5 symptoms, including her low mood, not enjoying being a new
mother, feeling disconnected from the baby, guilt, anxiety, withdrawing, and lack of support based on
the comment by her mother-in-law meet criteria for perinatal depressive disorder and make for an
unhealthy environment for the mother and infant (Carlson et al., 2024).
, NR 606 Week 2 Discussion Preparing the Discussion
o Natalie is diagnosed with peripartum depression. Identify the appropriate treatment for
Natalie and discuss why the selected treatment is appropriate for the client.
Appropriate treatment for Natalie should take into consideration her continued breastfeeding.
According to Carlson et al. (2024), The recommended treatment of mild to moderate perinatal
depression would be psychotherapy, more specifically, cognitive behavioral therapy (CBT) and
interpersonal therapy (IPT). Psychotherapy (CBT and IPT) in combination with antidepressants is
recommended for moderate to severe depression. Additional referrals to postpartum support groups
and behavioral health resources offering support from contemporaries with little to no cost. The
American College of Obstetricians and Gynecologists (ACOG) recommends the use of selective serotonin
reuptake inhibitors (SSRI) as a first choice. If proven ineffective, serotonin-norepinephrine reuptake
inhibitors (SNRI) or mirtazapine (Carlson et al., 2024).
MY RECOMMENDATION: Sertraline 50mg po daily in the am. Adjustments can be made as needed;
consider a 2-week follow-up.
Although there is reassuring research regarding the safety of this medication, we have to be completely
transparent with our patients. It has shown efficacy in treating postpartum depression, but trace
amounts of the medication have been found in breastfed infants (Stahl, 2020). Keeping this in mind,
reiterating the values of breastfeeding and the risk associated with untreated depression for mother and
baby is essential. Research has shown that the combination of CBT and medication has shown
improvement shortly after treatment startup (Carlson et al., 2024).
o Natalie has concerns about the stigma associated with seeking mental health care. Discuss
at least two (2) strategies the PMHNP can use to address these concerns.
Based on Natalie’s mother-in-law's comment, the stigma is real. This judgment leads to personal
concerns about where Natalie is falling short, leading to concern, judgment, and confusion. Moore et al.
(2018) identify two significant stigmas: internal and external. The difference is that external stigma is
extreme disapproval from someone regarding your mental health state, and internal stigma is negative
self-judgment regarding your thoughts and feelings regarding your mental health state. As a Psychiatric
Mental Health Nurse Practitioner (PMHNP), education is one of the most essential evidence-based
interventions. You are responsible for educating your patient and her family. You can do this during
office visits when Natalie brings her husband and mother-in-law in. Another strategy noted by Moore et
al. (2018) states that online forums for perinatal mental health can benefit members. Finding comradery
with other forum participants encourages these women to feel less like failures or bad moms, knowing
they are not alone; they feel supported and understood and more open to seeking treatment.
Community-based postpartum support groups and behavioral health resources can reduce stigma and
discrimination and improve mental health outcomes by normalizing, decreasing stigmatization, and
making treatment options and services more accessible (Ahad et al., 2023).
,
Dr. Zimmerman and classmates;
Natalie is a 32-year-old who gave birth to a healthy baby girl 12 weeks ago. Two years ago, she had a
stillborn son. Natalie was initially very excited about the birth of her baby and thrilled to receive
attention from extended family and friends. Over the past two weeks, she has become withdrawn,
anxious, and feeling very guilty about the fact that this baby survived when her son did not. She has
continued to breastfeed but feels “disconnected” from the baby. Natalie’s only contact with health
care providers since delivery has been her obstetrician for a 6-week follow-up and her daughter’s
pediatrician for the 1-month and 2-month well-baby visits. Natalie’s mental health was not addressed
at either visit. She has sought care with the psychiatric mental health nurse practitioner (PMHNP)
because she is concerned about her mental health. Natalie has no history of a mental health diagnosis
and is anxious about the stigma of seeking treatment for her low mood, especially since her mother-
in-law told her that she should have “bounced back” by now.
o Identify the appropriate screening tool for Natalie to complete during her first visit and
discuss why the selected tool is appropriate for the client.
The recommended screening tool for Natalie would be the Edinburgh Postnatal Depression Scale
(EPDS). A highly respected, reliable tool (Mastrangelo, 2022). This recommendation is endorsed by the
American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics
(AAP), and the American Academy of Family Medicine (AAFP). The EPDS includes screenings for drug
and alcohol history, smoking habits, and all prescription and over-the-counter drug medications. This
screening is a 10-item self-administered questionnaire that only takes a few minutes. Scoring 13 or
greater indicates a risk of developing depression, and further assessments need to be done to evaluate
the patient (Carlson et al., 2024).
The American College of Obstetricians and Gynecologists (ACOG) recommends at least one screening
during perinatal visits; the patients should be monitored for changes or increased symptom
presentation (Carlson et al., 2024). The ACOG further states that this screening process should be
continued throughout pregnancy, personalized to each patient’s needs. Best practice guidelines support
additional screening postpartum check-in at three weeks and no more than 12 weeks post-partum
(Ellington, 2021). Strengthening the recommendation for screening, the U.S. Preventive Services Task
Force recommends screening new mothers at well-baby checkups 1, 2, 4, and 6 months using the EPDS
(Mastrangelo, 2022).
Unfortunately, Natalie is 12 weeks post-partum, and over the past two weeks, she has developed these
symptoms. I would have thought that with the history of a stillborn, a significant risk factor, she would
have been under the radar of her caregivers and family to be susceptible to the occurrence of a
depressive episode. According to Carson et al. (2024), although she is more than four weeks postpartum
the two weeks of, a minimum of 5 symptoms, including her low mood, not enjoying being a new
mother, feeling disconnected from the baby, guilt, anxiety, withdrawing, and lack of support based on
the comment by her mother-in-law meet criteria for perinatal depressive disorder and make for an
unhealthy environment for the mother and infant (Carlson et al., 2024).
, NR 606 Week 2 Discussion Preparing the Discussion
o Natalie is diagnosed with peripartum depression. Identify the appropriate treatment for
Natalie and discuss why the selected treatment is appropriate for the client.
Appropriate treatment for Natalie should take into consideration her continued breastfeeding.
According to Carlson et al. (2024), The recommended treatment of mild to moderate perinatal
depression would be psychotherapy, more specifically, cognitive behavioral therapy (CBT) and
interpersonal therapy (IPT). Psychotherapy (CBT and IPT) in combination with antidepressants is
recommended for moderate to severe depression. Additional referrals to postpartum support groups
and behavioral health resources offering support from contemporaries with little to no cost. The
American College of Obstetricians and Gynecologists (ACOG) recommends the use of selective serotonin
reuptake inhibitors (SSRI) as a first choice. If proven ineffective, serotonin-norepinephrine reuptake
inhibitors (SNRI) or mirtazapine (Carlson et al., 2024).
MY RECOMMENDATION: Sertraline 50mg po daily in the am. Adjustments can be made as needed;
consider a 2-week follow-up.
Although there is reassuring research regarding the safety of this medication, we have to be completely
transparent with our patients. It has shown efficacy in treating postpartum depression, but trace
amounts of the medication have been found in breastfed infants (Stahl, 2020). Keeping this in mind,
reiterating the values of breastfeeding and the risk associated with untreated depression for mother and
baby is essential. Research has shown that the combination of CBT and medication has shown
improvement shortly after treatment startup (Carlson et al., 2024).
o Natalie has concerns about the stigma associated with seeking mental health care. Discuss
at least two (2) strategies the PMHNP can use to address these concerns.
Based on Natalie’s mother-in-law's comment, the stigma is real. This judgment leads to personal
concerns about where Natalie is falling short, leading to concern, judgment, and confusion. Moore et al.
(2018) identify two significant stigmas: internal and external. The difference is that external stigma is
extreme disapproval from someone regarding your mental health state, and internal stigma is negative
self-judgment regarding your thoughts and feelings regarding your mental health state. As a Psychiatric
Mental Health Nurse Practitioner (PMHNP), education is one of the most essential evidence-based
interventions. You are responsible for educating your patient and her family. You can do this during
office visits when Natalie brings her husband and mother-in-law in. Another strategy noted by Moore et
al. (2018) states that online forums for perinatal mental health can benefit members. Finding comradery
with other forum participants encourages these women to feel less like failures or bad moms, knowing
they are not alone; they feel supported and understood and more open to seeking treatment.
Community-based postpartum support groups and behavioral health resources can reduce stigma and
discrimination and improve mental health outcomes by normalizing, decreasing stigmatization, and
making treatment options and services more accessible (Ahad et al., 2023).
,
