Autonomy has always been the humans basic need in order to make firm identity and to be acountable on ones own self.Individual autonomy is an idea that is generally understood as the capacity to live life according to reasons and motives that are taken as one’s own and not the product of manipulative or distorting external forces.According to Almeida (2010),”autonomy is define as power of self over oneself, thefreedom. It is the individual’s sovereign over himself ,his body and mind”

Being confined to health care setup, autonomy plays a vital role in medical decisions. According to human rights and legislation by WHO (2005), patient is autonomous of refusing or selecting any mode of treatment and maximum freedom is provided to him.But it has been more challenging when needed to be followed in mental health care where patient’s rights must be secured while maintaining his dignity but at the same time improving his health as well,which remains an ethical dilemma.In socio-cultural context autonomy is considered as ethically and legally controversial issue. In western society, taking a client-centered approach, patient’s dignity and autonomy are given more importance as compared to Eastern society, where physicians and nurses are considered authoritative and given right to do what is better for patient.( Firoozabadi & Bahredar, 2009)

The reason for the selection of this topic is that as a nursing student, I found that autonomy is one of the most important ethical issue in mental health care setup. As Psychiatric patients usually have altered perception of reality which makes it difficult for the care provider to explain them the plan of care but at the same time protecting their rights as well, which make it an ethical dilemma for nurses but a great matter of concern as well. This paper will elucidate upon the importance of autonomy the significance of advance directives in mental health care mainly dealing with autonomy crisis.

A 28 years old woman was admitted at karwan-e-hayat with the diagnosis of schizophrenia. She was admitted with the complains of suspiciousness and aggression. She was suspicious with the staff and was refusing medicines due to paranoid delusion.The staff had given her medicines forcefully.As a result she gets aggressive and need to be restrained usually at the time of medicines.According to staff they had to deal these types of patients forcefully in order to improve their health.Although giving medications may improve her mental health but on the other hand forcing her generates the feeling of being dependent and compromised self-identity. Moreover, studies have shown that taking patient’s all of the autonomy have negative psychological outcomes on patients.while the patient with autonomy acquire positive attitude and high self esteem and as they are optimistic about future and feel empowered so they recover earlier than those with no autonomy(sakellari,2008)

According to WHO(2003),450 million people worldwide suffer of a mental or behavioral disorder.Is this significant population should be put in category of no autonomy just because they are mentally ill?.As they have been tagged as psychiatric patient and they don’t have decision making capacity hence there psychiatrist will take all decisions.If this is called as beneficence so we are just observing one side of the coin. A mentally ill patient usually has low self-esteem due to the stigmatization by the society and even their own family.Furthermore when the health care setup in the name of beneficence take over their autonomy, it shatters their dignity and self-respect and when patient gets aggressive and not participative due to being less autonomous ,soon we document the symptoms.

Even a normal person also gets angry when treated forcefully.Here the point of view is that giving all the autonomy to health care professional just because patient is mentally ill is not the only solution.A mutual decision should be taken to satisfy patient and not to harm him as well. As in the above case scenario patient was not ready for taking medication and following treatment but at the same time medications were important for him but giving him forcefully seems a psychiatric patient with no autonomy.

Psychiatric advance directive has found to be one of the more promising innovations in recent years to give patients a greater voice in their psychiatric treatment.It involves patient and his family in making decisions, fosters better collaboration between care providers and patient. Individual feels that he has some control over his life, and has input into the course of treatment, thus does not feel helpless,or dependant on others. According to (Elbogen et al., 2007) “Psychiatric advance directives are legal tools allowing mentally ill individuals to document prospective treatment choices in the event of becoming incompetent in the future”.However it was first practiced by scotland in 2003 when included in scotland’s “Mental Health Act 2003”.

Advance directive help patient to make decisions about his treatment. It is the way of encouraging patient and care provider to negotiate on mutually agreeable care plan.As a result patient remains autonomous and treatment process is also not hindered(Appelbaum,2004).It will not change the course of treatment but will explain it in ethical way as in the above mentioned case patient’s medicines are improving patient’s health but except of forcing the patient and violating the autonomy if advance directive would have been followed prior to it,It may have helped nurse in handling the patient and patient might not be aggressive.

According to Srebnik & Fond(2007), psychiatric advance directives are divided into two major classes.Instructional directive contains instructions in the form of living will by the patient in advance that tell care providers that how to handle a patient in any mental health crisis. whereas proxy directive allows an individual to designate someone else either family member or closed one,to make medical decisions on patient’s behalf. Proxy directives are most commonly used in mental health where another person who is mentally competent and on which patient trusts most, take the decisions on patients behalf.As in the above senerio instead of forcefully giving medications to the patient by staff a close one or a family member whom which patient trust the most have took the decision so patient might would not be suspicious and aggressive.

According to shared decision making model (Adams et al.,2007) patient should have equal participation in making decision for care plan along with the health care provider as it promotes patients autonomy and motivates patient participating actively in treatment and reducing anxiety of patient. Advance directives has proven to be an efficient way for including patient in his own treatment plan as before directives particularly psychiatric patients were not the part of decision making . But like other patients psychiatric patient can equally get involve in their treatment

In Pakistan advance directives in psychiatric setup has not been practiced yet and nor it has been included or supported by mental health Act though it has been practiced in critical care since many years. Furthermore very less population is aware of it due to which autonomy crises have not been significantly reduced. But due to the emerging role of advance directive in mental health, it is needed to be included in mental health Act but also making it compulsory.Secondly staff and the health care professional should be taught using the advance directives and legal and ethical formalities fulfilled at the time of signing the legal document. Lastly patients and their families should be given awareness about it because most of the time legal Acts are available but due to lack of knowledge, not used.

In conclusion autonomy has always been a leading ethical issue in mental health care where beneficence overrides it but use of advance directives provides patient autonomy for making treatment decisions and helps care provider giving care being in an ethical context.Advance directives not only act as solution for ethical issues but also contribute in increasing patient’s self esteeem,self respect and feeling of empowerment.It is needed to be the part of mental health care setup and patients should be aware of using it as it gives a mutual path of not voilating autonomy and improving health as well.

Madeleine Leninger was born on July 23 1925 in Sutton, Nebraska. She is a Fellow of the Royal College of Nursing in Australia, and a Fellow of the American Academy of Nursing. Her theory of Culture Care is now a nursing discipline. In this modern health care system, nurses should consider culture as an important aspect to provide holistic care.

Rationale for selecting Leininger’s theory

We selected Madeleine Leininger’s Theory of Culture Care: Diversity and Universality for our clinical practice with many reasons. We observe diversity among our patient population on a daily basis. Patients come from different cultures with different values and beliefs. One practice that is accepted in one society or culture may not be accepted in another culture. Patients have the right to get the care based on their cultural values and beliefs. For this reason, it is one of the major responsibilities of nurses to provide culturally competent holistic care to improve patient outcome. For this reason it is of utmost importance to promote cultural competence among all nurses. Leininger (2006a: 16) refers to culturally congruent care as ‘knowledge, acts, and decisions used in sensitive and knowledgeable ways to appropriately and meaningfully fit the cultural values, beliefs, and life ways of clients for their health and well-being, or to prevent illness, disabilities, or death.

Biography of Madeleine Leininger

Madeleine Leininger is well known to as a nursing theorist who developed transcultural nursing model. She was born in Sutton, Nebraska in July 23, 1925. She

received her nursing diploma from St. Anthony’s School of Nursing in Denver, and in 1950, she received her bachelor of Nursing from St. Scholastica College. She completed her Master of Science in mental health nursing from Catholic University of America in 1954. She attended University of Washington in 1965 and studied cultural and social anthropology in which she was awarded a Ph.D. In her earlier years in the nursing profession, she realized “care” as one of the important function in nursing. Transcultural nursing was an idea that was formulated by Leininger when she realized that the behaviors of the children in the guidance home were recurrent patterns from their cultural background. Transculture theory was developed to provide nursing care in a holistic and comprehensive approach. Her theory gives nurses avenues on how to provide care in harmonious way through applying the patient’s cultural beliefs, values and practices.

Classification of the Theory

McEwen & Wills (2011) places Leininger’s Theory in the high middle range theory classification based on the level of abstraction or degree of specificity. Leininger states that it is not a grand theory because it has particular dimensions to assess for a total picture. It is a holistic and comprehensive approach, which has led to broader nursing practice applications than is traditionally expected with a middle-range, reductionist approach .

Assumptions of Theory of Culture Care

The central focus of the theory is care. Caring is important for health, well-being, healing, growth, survival, and for facing illness or death. Culture care is a wholistic approach to serve human beings in health, illness and dying. There is no cure without giving and receiving care. Concepts of culture care have different and similar aspects in different parts of the world. Each human culture varies in folk remedies, professional knowledge and practice. Knowledge regarding this variation is important for the nurses to know to provide quality care. Worldview, language, religious, spiritual, social, political, educational, economic, technological, ethno historical, and environmental factors affect culture care values, beliefs and practices. Healthy applications of culturally based care promote the wellbeing of the patient. Thorough knowledge of the culture is necessary to provide competent care to the clients. Clients who experience nursing care without incorporating the cultural issues experience stress, cultural conflict, noncompliance, and ethical moral concerns.

Major concepts of the theory

Understanding of major concepts of theory is important to understand the whole theory. Care is to assist others with real or anticipated needs in an effort to improve a human condition of concern or to face death. Caring is an action or activity directed towards providing care. Culture refers to learned, shared, and transmitted values, beliefs, norms, and life ways of a specific individual or group that guide their thinking, decisions, actions, and patterned ways of living. Cultural care refers to multiple aspects of culture that influence and enable a person or group to improve their human condition or to deal with illness or death. Cultural care diversity refers to the differences in meanings, values, or acceptable modes of care within or between different groups of people. Cultural care universality refers to common care or similar meanings that are evident among many cultures. Person refers to an individual human caring and cultural being as well as a family, group, a social institution, or a culture. Nursing is a learned profession with a disciplined focused on care phenomena. Worldview refers to the way people tend to look at the world or universe in creating a personal view of what life is about. Cultural and social structure dimensions include factors related to religion, social structure, political/legal concerns, economics, educational patterns, and the use of technologies, cultural values, and ethno history that influence cultural responses of human beings within a cultural context. Health refers to a state of well-being that is culturally defined and valued by a designated culture. Cultural care preservation or maintenance refers to nursing care activities that help people of particular cultures to retain and use core cultural care values related to healthcare concerns or conditions. Cultural care accommodation or negotiation refers to creative nursing actions that help people of a particular culture adapt to or negotiate with others in the healthcare community in an effort to attain the shared goal of an optimal health outcome for client(s) of a designated culture (Summarized from Leininger, 2001, pp. 46-47).

Major Propositions of the Theory

Leininger (1991) proposes that there are three modes for guiding nurse’s judgments, decisions, or actions in order to provide appropriate, beneficial, and meaningful care. They are cultural preservation or maintenance, cultural care accommodation or negotiation, and cultural care repatterning or restructuring. Cultural preservation or maintenance retain or preserve relevant care values so that clients can maintain their well-being, recover from illness, or face handicaps and/or death. Cultural care accommodation or negotiation adapt or negotiate with the others for a beneficial or satisfying health outcome. Cultural care repatterning or restructuring records, change, or greatly modify client’s life ways for a new, different and beneficial health care pattern (Leininger, 2002). The modes have greatly influenced the nurse’s ability to provide culturally congruent nursing care, as well as fostering culturally-competent nurses. These three modes of action can lead to the deliverance of nursing care that best fits with the client’s culture and thus reduce cultural stress and chance for conflict between the client and the caregiver.

Examples from the literature of how the theory been used

According to the article the expression of pain and its management has social and cultural facts that affect the biological state of the person, therefore many societies and cultures have their own ways and perception to pain and how they treat it. In this article the nurses who were giving care to the patient used the international treatment guideline which is a stepwise approach to the treatment of chronic non-cancer pain, involving not only over-the counter anti-inflammatory drug, but also lower dose opioids (Lu & Javier, 2006). The nursing decisions that were used in this article are cultural care accommodation and negations in which the nurses incorporated the holistic approach of using “hilot.” Hilot is a form of traditional Filipino healing massage; the patients were allowed to use natural topical ointment which is commonly found in their culture for relief of pain. This process allowed the patients to be comfortable with the care that they received due to incorporating cultural believes with western medications. This also allowed the patient to have knowledge that is related to the treatment of pain, cultural values and heritage especially in the older population who view pain medication such as opioids and administration of it as addictive and would rather suffer through it than to use it. The rational for this is because of the beliefs in the Filipino culture by both prescribing doctors, nurses who administer the medications and the patient that there will be high incidents of the patient becoming addicted opiods when used in treating chronic pain.

Action plan

The theory of Madeleine Leininger’s will be integrated into practice in the work place by first reviewing the care and cultural values that fits the patient. This will be done by the way the nurse approach, work with and assist or help the patient. The integration will be approach through culturally congruent care or care that fits the culture, because care is enabling process by which the nurse will facilitate assist, guide and help the patient to link what the nurse is trying to help them in the treatment of their disease. This approach will help the nurse mange the diseases from a unique cultural perceptive of the patient. The nurse will monitor home remedies that are unique to the patient during admission and determine if any of them are contraindicated with the medications which the patient was taking. Also integrating religious rituals into the care plan can help make a significant impact on the success of the patient’s treatment; it will impact on the perception of the patient’s health, disease process and treatment. With the patient’s permission, involving close family member can give the patient emotional support. Including respect of cultural values may allow the patient to express themselves to the nurse because they may view this as a sign of respect. When a nurse is having difficulty

to get the patient to buy into to a particular treatment, negotiating will help them adapt without compromising the patient’s values. When the nurse develops the basic understanding of health behavior of a culture, this helps to have a positive impact on the nurse-patient relationship.

Concrete examples of how theory would be integrated

During assessment, the plan of care for the patient will be established. This will give the nurse clear concise pertinent information about the patient. Cultural needs such as language barrier, dietary restrict, and beliefs will be assessed. Also rituals that may affect the patient’s care such as dietary restrict will be considered. An example is if the patient is Jewish, or Seventh day Adventist food product or meat made from pork should be omitted from their dietary tray. Meal planning is important because diet plays such an import healing process in the patient’s illness. Language barrier is another cultural issue that may arise during the patient’s stay in the hospital. Using the right interpreter such as someone who is certified and competent in the patient’s language is beneficial to prevent the wrong information being given to the patient. All these will be beneficial, helpful, assistive, and therapeutic in the board sense to maintain an open communication between the nurse and the patient.

Conclusion

In today’s healthcare field, it is required for nurses to be sensitive to their patients’ cultural backgrounds when creating a nursing plan. This is especially important since so many people’s culture is so integral in whom they are as individuals, and it is that culture that can greatly affect their health, as well as their reactions to treatments and care. The practice of nursing today demands that the nurse identify and meet the cultural needs of

diverse groups understand the social and cultural reality of the client, family, and community, develop expertise to implement culturally acceptable strategies to provide nursing care, and identify and use resources acceptable to the client (Boyle, 1987).

When Leininger’s Transcultural Nursing theory guides nursing practice, nurses can look at how a patient’s cultural background is involved in his or her health, and use that knowledge to create a nursing plan that will help the patient get healthy quickly while still being sensitive to his or her cultural background. Nursing is in a new phase of health emphasis where there is an increased display of cultural identity, accompanied by increased demands for culture specific care and general health services.  Unquestionably, it is the theory of today and tomorrow and one which will grow in use in the future in our growing and increasingly multicultural world. The research and theory provide a new pathway to advance the profession of nursing and the body of transcultural knowledge for application in nursing practice, education, research, and clinical consultation worldwide.

In this assignment the author will consider the chronic condition Heart Failure. The author will analyse the effectiveness of care management given to a patient with heart failure and depression. The Patient identity, in accordance with the NMC (2008) Code of professional conduct, will remain confidential. For the Purpose of this assignment the patient will be called Mr. Singh.

The role of some health care professionals will be discussed to show the importance of, and how working collaboratively can help promote autonomy and independence. Issues concerning therapeutic and complimentary therapies will be looked at in relation to depression. Professional, statutory, and government frameworks will be analysed to find out how they affect nursing and clients with chronic health problems. Health education and health promotion will be analysed in relation to the nurse.

The patient Mr. Singh Is a 68 year old Asian male with chronic heart failure. The Patient has Vitamin B12 deficiency, severe depression, anemia and dependent oedema. Mr. Singh has right-sided Heart failure and has experienced Swelling of feet and ankles, Fatigue, and heart palpitations. Mr. Singh’s wife is fit and well and they have 4 daughters and several grandchildren who visit regularly.

Heart failure is progressive disorder; damage to the heart causes a weakening of the cardiovascular system. Heart failure appears through fluid congestion or inadequate blood flow to tissues (Romeo et al, 2006) Heart failure can be caused by a heart injury or an inappropriate response to heart impairment (Romeo et al, 2003 and Bupa, 2009). According to European Society of Cardiology (2008) coronary artery disease is the leading cause of heart failure by 70%.

Heart failure can affect different sides of the heart, ‘right heart failure’ reflect congestion of the systemic veins with symptoms of dependent oedema, the liver is enlarged, and the jugular veins are distended. ‘left sided heart failure’ affects the pulmonary veins. With left heart failure, there are features of pulmonary oedema and symptoms of breathlessness chest x-rays will show signs of excess fluid in the lungs (NHS, 2006). Heart failure is more common in men and affects those over 65, People of South Asian descent are at high risk for heart disease according to AHA (2004).

Heart Failure can impact on a patient psychologically and socially. This is important as well. Up to a third of people with heart failure develop severe depression (DH, 2000; Thombs et al, 2008). Depression is a mental disorder that is fairly common, it presents with depressed mood, loss of interest, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.

People who have Depression is estimated to be 100 cases per 1000 persons in the population more than 65 years old (Mcmurray et al 2000) Evidence suggests that there is a link between depression and an increase in morbidity and mortality in patients with heart failure and that men with heart failure are more likely to become depressed

than the general population (Thomas et al 1997) . Studies around heart failure and depression have shown that the manifestations and prognosis of depression is also recognised as a risk factor for heart failure. Some preliminary studies have suggested that , with concurrent depression may result in adverse clinical outcomes in people with heart failure, including higher mortality rates (Mcmurray et al 2000).

Complimentary therapies are used for healing practice “that does not fall within the realm of conventional medicine”, (Bratman and steven 1997) complimentary therapies are often different to evidence based medicine and include therapies with an historical or cultural basis, rather than a scientific basis. Studies have suggested potential effectiveness for certain complementary and alternative medicine interventions for depression and anxiety in older adults, these theories however need more vigorous research is required (Meeks 2007)

Ernst & White,2000 and Thomas et al,2001 suggest that Complementary therapies are gaining in popularity finding they have more importance in health care (Peters et al,2002). Health care professionals have created more of an interest in complementary therapies and they are more widely integrated into nursing and midwifery (Ong & Banks, 2003). The Midwifery Council (NMC,2008) Code of Professional Conduct requires that nurses and midwives must be convinced of the safety and relevance of any therapy that are used, and should be able to justify its use when introducing complementary therapies. It is important that any therapies used are of interest of the client and should be within the best interests and safety of clients. Although studies have shown that complimentary therapies need more research, this could help give some improvement to Mr Singh’s depression, if improvements are made, this could reduce the risk of more heart problems.

Health Promotion is an important part in a nurses role of care to a patient/client (NMC 2008). Even before looking at how patients receive health promotion advice, a consideration should be given for their approachability and willingness to receive that advice. Prochaska and DiClemente’s model of readiness to change is a good example of this (Budd et al 1996). In resent years of health promotion the locus of control is a concept that has changed in both emphasis and definition. It is probably fair to comment that in the mid part of the last century, the emphasis of control was with an instructive approach from the healthcare professionals. The patients were given instructions and were expected to obey (Martyn 1999). Practice today prefers an understanding and an agreement, which is reached after a discussion that involves the patient as much as it involves the healthcare professional (Richards 1999). As discussed previously the theory of patient empowerment and education is seen to be an important part of increasing patient compliance. In due course, the locus of control stays with the patient, as they will decide on how, when and how much they will comply with the treatment plan, they will decide whether or not to be empowered to change their life (Bandura, 2007). Healthcare professionals are seen as a resource of knowledge, this allows for the process of concordance to take place (RPSGB, 1997).

Diet is also an important factor in changing Mr. Singh’s lifestyle, and trying to improve his heart function; a dietitian would give examples and give health education on how to change his diet. Loosing weight will help to reduce the hearts effort. Salt can cause water retention; Mr. Singh should reduce the amount of salt in his diet (FSA 2010). The dietitian would teach Mr. Singh and his family where to look for hidden salts in food. Diet Plans can be written up and the best food chosen to ensure salt is reduced from Mr. Singh’s diet. Mr. Singh should be advised not to replace salt with salt substitutes; many of these are high in potassium, because they may enhance the “potassium-sparing effect of angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, and aldosterone antagonists.” (FSA 2010).

Postpartum Depression is generally defined in the following context: “Specifier of nonpsychotic major depression that has its onset within 4 weeks after delivery” (Mehta and Sheth, 2006). In addition, the illness is often classified into the following categories: “Baby blues,” “nonpsychotic depression,” and “puerperal psychosis” (Mehta and Sheth, 2006). Therefore, the illness is complex in nature and is attributed to the emotions that are experienced after giving birth (Mehta and Sheth, 2006). It appears that there are no clear distinctions between first-time and experienced mothers facing postpartum depression, and that the state is potentially dependent upon hormonal imbalances (Mehta and Sheth, 2006). The state of postpartum depression is particularly difficult for its sufferers, as they are often unable to care for their newborn babies in the way that they desire, and this places a particularly difficult strain upon the family in these cases. The defining attributes of the illness are emotional in nature, and require further evaluation in order to establish a successful diagnosis and treatment strategy.

For women facing the risk of postpartum depression, there are a number of common concerns that are well-defined and researched, including but not limited to stress, hormone imbalance, and alternative methods of conception. Therefore, those women facing postpartum depression often possess a number of risk factors that may be individual or combined. As a result, a diagnosis of this condition is often based upon several factors. However, these factors may also be attributed to other conditions and circumstances, so how they are identified and managed is of critical importance in addressing the condition directly. In general, “A meta-analysis of numerous studies found the average prevalence rate of postpartum depression to be 13 %…there is a three-fold increase in the risk of depression during the first months after delivery” (Joesfsson, 2003, p. 14). Therefore, it is important to note that postpartum depression is a common condition that requires further evaluation and treatment.

A case study is perhaps the most feasible opportunity to explore the variables involved in postpartum depression, as this will enable the evaluator to determine the extent to which the illness is based upon various factors, how it was derived, and how to best treat the condition effectively. Typically, a scale known as the Edinburgh Postnatal Depression Scale (EPDS) is widely used to identify the severity of postpartum depression episodes, as is useful in determining the course of treatment that will treat the condition without delay (Chokka, 2002).

One case to consider is that of using the EPDS to screen patients for postpartum depression, and if the condition is identified, to determine its severity (Joesfsson, 2003). This scale is used to convey a greater understanding of the epidemiology of the illness, and its contributing factors in those that suffer its symptoms (Joesfsson, 2003). The case study under consideration examines women facing postpartum symptoms of depression at several intervals, and explores a number of variables that are relevant in describing the condition and its potential outcomes for female patients (Joesfsson, 2003). There were a number of statistical requirements under consideration, as well as an opportunity to explore the ethical nature of the study and how it might impact postpartum women in a personal manner: “We questioned ourselves whether it would create increased anxiety to ask the eligible women personal questions about mental and physical health and later on about their children’s behavior. However, we concluded that the positive effects would outweigh the negative effects and that the attendance rate would reflect the women’s opinions in this matter. Verbal and written information was given to all participants and it was made clear that participation was voluntary” (Joesfsson, 2003, p. 33). From this perspective, it should be noted that the postpartum depression study served as a means of influencing the identification of risk factors, as well as the epidemiology behind such factors and subsequent treatment alternatives that would be useful in supporting patients of this nature (Joesfsson, 2003). In this manner, it was determined that the study was a safe and effective means of identifying various risk factors associated with postpartum depression.

The study results indicate that the EPDS is a highly useful tool in order to support the findings associated with postpartum depression (Joesffson, 2003). One of the key factors in this study that is not found in many other studies is as follows: “An advantage of this study is that all data were extracted from standardized medical records in which data were collected prior to knowledge of postpartum mood. This made it possible to minimize maternal recall bias. To our knowledge this is the only study that includes earlier medical, gynecologic and obstetric history” (Joesffson, 2003, p. 37). Therefore, the study indicates that there are significant opportunities to explore postpartum depression by using the EPDS scale, and that the results from this scale will continue to provide clinicians with the tools that are necessary to improve diagnosis and treatment methods for postpartum depression and its many complexities (Joesffson, 2003).

EPDS is also evaluated in a borderline case involving postpartum women from Chile, and it was determined that the scale is very useful in other settings as a screening and diagnostic tool (Jadresic et.al, 1995). Another borderline case involving subjects from Iran is also useful in determining the effectiveness of the EPDS tool (Montazeri et.al, 2007). A contrary case involves the detection of false negatives in using the EPDS, which is in stark contrast to many other cases that support the widespread use of this scale to identify postpartum depression (Guedeney et.al, 2000). A case invented for the research might demonstrate that EPDS is successful in diagnosing other types of depressive disorders or episodes that extend beyond postpartum depression. Finally, an illegitimate case involves an examination of symptoms that are depicted as postpartum depression with the EPDS, but are actually not related ( Jomeen and Martin, 2008).

Based upon the model case, the antecedent is the series of unusual behaviors that are generally associated with postpartum depression, such a perceived detachment from the child, as well as emotions, such as uncontrollable crying and fits of anger. As a result of these behaviors, it is generally believed that women suffering from postpartum depression face considerable emotional and psychological consequences until they are diagnosed and are treated for their condition in a successful manner.

In a related case study, EDHS is utilized in conjunction with the Patient Health Questionnaire (PHQ-9) in an effort to identify postpartum depression in a different light. In a general context, “Routine depression screening has been recommended for all adults using tools, such as the Patient Health Questionnaire (PHQ-9), that have been validated in primary care practices” (Yawn et.al, 2009, p. 483). From this perspective, it is known that postpartum depression is not commonly considered under this questionnaire, and requires further consideration as a potential tool for evaluation of this condition (Yawn et.al, 2009). The study considered both tools as an opportunity to identify postpartum depressive symptoms, and to also demonstrate that these studies might be useful together, while also recognizing the limitations of their use in conjunction with each other (Yawn et.al, 2009). These findings suggest that there are significant factors involved in identifying postpartum depression, particularly when a body of questions are asked of each study participant that might be uncomfortable to answer (Yawn et.al, 2009). Therefore, it is difficult to identify all of the possible implications of using both tools without further evaluation (Yawn et.al, 2009). Nonetheless, it is very important and relevant to consider how postpartum depression is diagnosed and treated under the most common conditions.

Other studies also demonstrate that postpartum depression, when diagnosed by using the EPDS scale, is highly responsive to different forms of cognitive therapy, including individual and group counseling, amongst other methods (Moss et.al, 2009). However, studies do not go so far as to say that educational programs are a useful tool in supporting the prevention of postpartum depression, as this has yet to be identified as an effective alternative (Moss et.al, 2009). There continue to be critical factors that influence postpartum depression that have not been fully identified, and therefore, the EPDS is a very useful method of deciphering new problems and potential treatment solutions (Moss et.al, 2009).

Based upon the indicators provided in the discussion and case studies thus far, there are a number of empirical referents to consider when addressing the scope of postpartum depression, and how it is dramatically influenced by various factors, including but not limited to risk factors, symptoms, diagnosis and treatment. It is clear that there are a number of common risk factors associated with postpartum depression that are common in many identified cases, including but not limited to prior depressive episodes, hormone imbalances, and other related factors. These factors are typical contributors to the condition, even though their severity varies from one case to another. Nonetheless, when considering postpartum depression, these are typical concerns that must be evaluated on a consistent basis.

In one context, it is observed that postpartum depression may be associated with what is known as the “relinquishment of motherhood,” which is reflective of different circumstances, such as giving up a baby for adoption, as well as the challenges associated with postpartum depression (La Monica). In this context, “Relinquishment is usually done with a great deal of conflict, especially if done under compulsion. Consequences of relinquishment are (1) the obvious loss of a child, (2) a resulting role change; she is no longer functioning as a mother, and (3) the inevitable grief process to follow” (La Monica, p. 269). From this perspective, it is clear that postpartum depression also falls into this category, and possesses empirical consequences for a mother until a diagnosis and treatment plan is satisfied. It is important for a mother facing postpartum depression to consider how this might impact her child or children, and how to best approach the situation in a delicate yet assertive manner. However, since the judgment of the mother is often poor as a result of her condition and she may be unable to think clearly, it is necessary to consider how the condition might be identified by a clinical professional, and thus treated accordingly. It is important for family members and clinicians to be involved as early as possible, so that the symptoms do not become so severe that irreversible consequences are inevitable, as occurs in some cases.

In all cases of postpartum depression, it is critical to develop an understanding of the underlying factors, causes, and diagnosis methods that are most common, so that all possible ideas are explored without severe repercussions for patients. Therefore, it is expected that in all cases of postpartum depression, establishing a diagnosis using the EPDS and/or the PHQ are of critical relevance in order to determine the most feasible course of action for the patient in question. This is a general rule that applies to almost any diagnosis, and requires ongoing consideration in order to achieve the desired level of effectiveness. It is imperative that these methods are utilized consistently from one case to the next in order to establish effective patterns for treating postpartum depression and its underlying causes.

In order to identify the various principles that are associated with a diagnosis of postpartum depression, it is necessary to develop a greater understanding of various risk factors that are associated with the illness and its outcomes for new and experienced mothers. It is evident that there are a variety of concerns that are associated with postpartum depression, and that these require further consideration and evaluation. Therefore, various research studies to date indicate that there are a number of relevant tools that are often utilized in order to understand the overall concepts associated with postpartum depression, and how to best diagnose and treat this complex psychological condition with physical undertones. The most common tools used to identify the condition are the EPDS and the PHQ, which are utilized to identify severity of the condition under different circumstances. Patients suffering from this illness must be cooperative and supportive in seeking a diagnosis and treatment, even though this is often a very difficult concept to grasp. Therefore, it is important for clinicians to be heavily involved in this process, so that patients are provided with the best possible outcomes for their condition, regardless of its severity. This will provide the greatest level of support during diagnosis and treatment to improve the condition through regular treatment and ongoing intervention as necessary.