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International Journal of Mental Health Nursing (2008) 17, 419427

doi: 10.1111/j.1447-0349.2008.00568.x

Feature Article

Effectiveness of home visits by mental health nurses for Japanese women with post-partum depression
Atsuko Tamaki
School of Nursing, University of Kindai Himeji, Himeji, Japan

ABSTRACT: Post-partum depression affects 1013% of Japanese women, but many do not receive appropriate treatment or support. This intervention study evaluated the effectiveness of home visits by mental health nurses for Japanese women with post-partum depression. Eighteen post-partum women met the inclusion criteria and were randomly allocated into the intervention (n = 9) or control (n = 9) group at 12 months after giving birth. The intervention group received four weekly home visits by a mental health nurse. Control group participants received usual care. Two women in the intervention group did not complete the study. Depressive symptoms and quality of life were measured at 1 and 6 weeks postintervention. In addition, participants completed an open-ended questionnaire on satisfaction and meaning derived from the home visits. Women in the intervention group had signicant amelioration of depressive symptoms over time and reported positive benets from the home visits, but there were no statistically signicant differences between groups. Signicant differences (P < 0.05) were observed at times 2 and 3 between groups in terms of increased median scores of physical, environmental, and global subscales, and the total average score of the World Health Organization/ quality of life assessment instrument. On the psychological subscale, signicant differences (P = 0.042) were observed between groups at time 2. The qualitative analysis of comments about home visitation revealed four categories related to setting their mind at ease, clarifying thoughts, improving coping abilities, and removing feelings of withdrawal from others. These results suggest that home visits by mental health nurses can contribute to positive mental health and social changes for women with post-partum depression. A larger trial is warranted to test this approach to care. KEY WORDS: home visit, mental health nursing, post-partum depression, quality of life, Japanese women.

INTRODUCTION
Post-partum depression affects approximately 1013% of Japanese women (Okano et al. 2007; Yamashita et al. 2000), similar to rates seen in Western countries (OHara & Swain 1996). Several qualitative studies have revealed high-distress symptoms in women with post-partum
Correspondence: Atsuko Tamaki, School of Nursing, University of Kindai Himeji, 2042-2 Oshio, Himeji, Hyogo 671-0101, Japan. Email: atsuko_tamaki@kindaihimeji-u.ac.jp Atsuko Tamaki, RN, PHN, PhD. Accepted July 2008.

depression (Beck 1992; 1993; 1996; Chan et al. 2002; Nahas et al. 1999; Ugarriza 2002). Post-partum depression can negatively inuence motherchild interactions (Stein et al. 1991), childrens development (Beck 1998; 1999; Murray et al. 1999), and the mental health of partners (Deater-Deckard et al. 1998; Lovestone & Kumar 1993). In light of these consequences, a Japanese government report in November 2000 emphasized the need for the prevention, early detection, and early treatment of post-partum depression. However, mental health support systems for post-partum women continue to be insufcient (Okano 2005), and many women with post-

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partum depression do not receive appropriate treatment or support (Tamaki 2007). The provision of mental health support between 1 and 4 months after giving birth is especially important as women might be at greater risk of post-partum depression at this time (Cooper & Murray 1995). At approximately 1 month after giving birth, many Japanese women return to their own home after staying with their parents (there is a traditional Japanese custom that post-partum women spend approximately 1 month at their parents home and receive support from their family). Furthermore, after their 1-month post-partum check up, new mothers have no scheduled health-care contact until 4 months after giving birth. The perceived lack of formal and informal support might precipitate emotional distress in some women. Several controlled studies have shown the efcacy of psychosocial interventions for post-partum depression (Brockington 2004; Dennis 2005; Lumley et al. 2004; Ray & Hoddnett 2002). In particular, home-based, individual intervention by nursing professionals or health visitors has been shown to be effective in preventing or minimizing the adverse impact of post-partum depression (Armstrong et al. 1999; 2000; Holden et al. 1989; Horowitz et al. 2001; MacArthur et al. 2002; Wickberg & Hwang 1996). However, only a few studies have reported the efcacy of an intervention by mental health nurses. Austin et al. (1999) found that a nursing assessment and early intervention (providing support, psycho-education, and advice and education on mothering) by experienced community mental health nurses produced high rates of recovery from depression and promoted close collaboration among other health professionals (midwives, early childhood nurses, general practitioners, and psychiatrists). However, their study was limited by the lack of a control group. Beeber et al. (2004) tested a short-term, home-based intervention by mental health nurses with 16 mothers with depressive symptoms. The intervention consisted of strategies for managing depressive symptoms, improving problematic life issues, increasing access to social support, and effective parenting. The intervention showed a signicant reduction in depressive symptoms and an improvement in motherchild interactions. All participants were retained in the study and reported high satisfaction with the intervention. However, that study targeted not only post-partum women, but also the mothers of toddlers. There is a dearth of randomized controlled trials testing the effectiveness of mental health nursing interventions to manage postnatal depression in the community, particularly in Japan, where there is a high level of

stigma associated with mental illness. In response to government priorities, this controlled intervention study aimed to evaluate the effectiveness of home visits by mental health nurses for Japanese women with postpartum depression.

METHOD Participants
Post-partum women attending a child health appointment at 1 month after giving birth were recruited between July 2004 and August 2006 at eight hospitals in Hyogo, Japan. Ethical approval was obtained from the Institutional Ethics Committee. All participants were Japanese women aged 18 years or older. Women were excluded if they lived outside the district, had delivered prematurely (before 36 weeks gestation), if their infant had any congenital or serious disease, if they did not have a singleton birth, or if they had received any antidepressant or other specic treatments during the study period.

Procedure
Women who agreed to participate provided informed consent and completed a screening questionnaire (Edinburgh Postnatal Depression Scale (EPDS)). Those who scored 9 or higher on the scale (indicating possible depression) were invited to enter the trial. Women were interviewed and assessed at home using a structured clinical interview to determine if they had a major or minor depressive disorder. Women who met the research criteria were allocated to the intervention or control group using computer-generated random numbers. For ethical considerations, if we considered that a woman needed treatment, we consulted a psychiatrist; the intervention and the assessment were stopped, and treatment was started as needed. The control group received routine care (e.g. a postpartum visit at home for the newborn with a midwife or a public health nurse and a 4-month post-partum check up at a community-based centre). In addition to routine care, the intervention group received four home visits by mental health nurses between 1 and 4 months after giving birth. Each home visit was at least 1 hour in duration. The intervention was based on the OremUnderwood model (Underwood 1985a; 1985b), a mental health/ psychiatric nursing model based on a self-care decit perspective (Orem 2001). The major aim of this intervention was to reduce depressive symptoms and improve womens quality of life. The intervention consisted of active listening, providing support and acceptance of the

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woman, psycho-education on depressive symptoms, and advice on coping strategies for problematic life issues, including parenting and increasing access to social or family support. The intervention was provided exibly according to the individuals needs and the nurses assessment of each womans self-care level and mental state. The validity of the intervention was conrmed by a descriptive study (Tamaki 2004). The intervention was delivered by three experienced female mental health nurses with a Masters degree. All nurses were trained before conducting the intervention so that they could provide the same content during the interventions. Written records were kept of each intervention session. To ensure that the intervention was consistently applied, case conferences were held every week and records were reviewed.

Measures
Depressive symptoms and quality of life were assessed at recruitment (time 1), 1 week (time 2), and 6 weeks postintervention (time 3) using three standardized measures. In addition, women in the intervention group were asked to describe how they perceived the home visits at times 2 and 3 using an open-ended questionnaire. The EPDS is a 10-item self-reporting scale specically designed to screen for post-partum depression symptoms in community samples (Cox et al. 1987). Each item is scored on a four-point scale (03), with the minimum and maximum total scores being 0 and 30, respectively. The scale was translated into Japanese and validated for a Japanese sample, giving a sensitivity of 75%, a specicity of 93%, and a positive predictive value of 50% using a cut-off score of 9 (Okano et al. 1996). The Structured Clinical Interview for DSM-IV AXIS I Modied Version for the Trans-Cultural Study of Postnatal Depression (SCID-PND) is a semistructured interview (OHara 1999). Gorman et al. (2004) reported that the SCID-PND was appropriate for assessing perinatal depression and other non-psychotic psychiatric illnesses. In the present study, the SCID-PND (Japanese version) was used by trained research mental health nurses (other than the nurses providing the intervention) who received 4 days of training in the use of the SCID-PND. The training included lectures, role plays, and discussions, and was led by a psychiatrist and the author. To ensure the reliability, the research nurses assessments were supervised by a psychiatrist. The research nurses who conducted the SCID-PND were blinded to the group allocation of the women. A short version of The World Health Organization quality of life assessment instrument (WHO/QOL-26)

was also used (Tazaki & Nakane 1997; The World Health Organization 1995). This ve-point self-rating instrument (15) has 26 items with ve subscales: physical (physical state), psychological (cognitive and affective state), social (interpersonal relationships and social roles in life), environmental (relationships to salient features of the environment), and global (meaning of life or overarching personal beliefs). An average score is calculated from the total of the ve subscales. A higher score indicates better quality of life. The Japanese version of this questionnaire is valid with respect to scaling, internal consistency conrmed by Cronbachs alpha, and discrimination properties (Yokoyama & Origasa 2003). In an open-ended questionnaire, women in the intervention group were asked to describe how they perceived the home visits in terms of satisfaction and meaning, and make other comments as appropriate about the intervention. For the rst assessment, a face-to-face interview using SCID-PND was conducted in the womens homes; the other two assessments were conducted by telephone interview. The three assessments were conducted by the same nurse for each woman. All of the self-reported questionnaires were distributed by the nurse, but completed at a later time by the woman and returned in a prepaid envelope.

Analysis
Within-group changes in the mean EPDS and quality of life scores at times and 2 and at times 1 and 3 were tested with Wilcoxon signedrank test. Differences between groups were tested with the MannWhitney U-test. To enhance the applicability of the EPDS, a correlation between the EPDS and SCID-PND results were tested with the MannWhitney U-test at times 2 and 3. The level of signicance was set at P < 0.05. Data from open-ended questionnaires were analyzed using a qualitative content analysis approach. Responses were classied and organized as meaning units. To assure reliability and trustworthiness, the process of categorizing data was scrutinized by two experts.

RESULTS
A total of 867 post-partum Japanese women were recruited and screened for post-partum depression with the EPDS; 361 (41.6%) women agreed to participate to the study. Sixty-six women (18.3%) scored above the threshold of 9 on the EPDS. Of these, 58 met the inclusion criteria and 40 (69.0%) agreed to enter the intervention trial. These women were interviewed at home by

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trained nurses at approximately 8 weeks after giving birth and assessed with the SCID-PND for major or minor depression. Of these 40 women, 19 (47.5%) were found to be depressed. One woman declined to participate after the interview. Thus, 18 women were randomized into an intervention (n = 9) or a control (n = 9) group. After the trial started, two women in the intervention group dropped out. They declined to continue receiving the intervention due to time constraints or the condition of their baby (Fig. 1). Table 1 shows details of the 16 women in the study. The mean age of the women was 33.8 years. All were married, and three lived with their parents (own parents or in-laws). Two women delivered their babies by Caesarean section, four women had undergone fertility treatment, and six had at least one episode of depression in the past. c2-test or MannWhitney U-test revealed no signicant differences between the groups in any of these variables. The mean (and SD) of each assessment time was as follows: time 1 (before the intervention) was 55.7 (SD 19.6) days after giving birth, time 2 (1 week postintervention) was 101.1 (SD 29.6) days after giving birth, and time 3 (6 weeks postintervention) was 137.7 (SD 33.6) days after giving birth.

(P = 0.027), global (P = 0.015), and the average score (P = 0.018) from times 1 to 2. From times 1 to 3, the intervention group showed signicant improvement for four subscales and the average score: physical (P = 0.028), social (P = 0.045), environmental (P = 0.018), global (P = 0.033), and the average score (P = 0.028). The control group showed no signicant within group differences in any quality of life parameter. Signicant differences (P < 0.05) were observed at times 2 and 3 between the two groups in terms of increased median scores for physical, environmental, and global subscales, as well as the average score. On the psychological subscale, signicant differences (P = 0.042) were observed between the groups at time 2 (Table 3).

Perceptions of the intervention


All intervention group participants reported on satisfaction and meaning derived from the intervention. From the qualitative data, four descriptive categories emerged, including setting their mind at ease, clarifying their thoughts, improving coping abilities, and removing feelings of withdrawal from others.
Setting their mind at ease

Effect of intervention
Depression

At time 2, according to the structured clinical interview, ve of seven (71.4%) women in the intervention group who were depressed showed no evidence of having depression at the second interview, whereas only three of nine (33.3%) women in the control group had recovered. At time 3, no woman in the intervention group showed evidence of depression, whereas six of nine (66.7%) women in the control group had recovered. The intervention group showed a signicant (P < 0.05) reduction in the median EPDS scores from times to 2 or time 3, whereas the reduction in the median EPDS scores of the control group was not signicant. Reductions in the EPDS scores between groups were not statistically different. The MannWhitney U-test revealed signicant differences in the EPDS scores and SCID-PND results between the women with depression and those without at times 2 (P = 0.021) and 3 (P = 0.014; Table 2).
Quality of life

This description category comprised the womens perceptions of being relieved or having theirs minds set at ease. Common statements included: You listening to my concern puts me at ease, I feel more secure after you listened to my thoughts, and Uneasiness has lessened and my hearts feels more stable.
Clarifying their thoughts

This description category comprised the womens perceptions of clarifying or realizing their thoughts, or recovering their composure. Common statements included: I realized my own thoughts and feelings while I was talking with you, My thoughts became clearer with your consideration and consultations, and Telling you my concerns stabilized my thoughts and feelings.
Improving coping abilities

A within-group comparison revealed a signicant improvement for the intervention group in four subscales, and the average score of the WHO/QOL-26: physical (P = 0.018), psychological (P = 0.017), environmental

This description category comprised the womens perceptions of improving their ability to cope with their husband or baby, understanding how to deal with stress or solve problems, and gaining self-condence. Common statements included: I have more condence since you acknowledged my childcare skills, Your suggestions gave me many ideas about how to cope with stress, and various creative ways of dealing with life stresses, I learned the importance of listening through my experience of being listened to. Now I can listen my husbands story/

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Screened participants (n = 867) Willing to enter intervention trial (n = 361) EPDS 9 (n = 66) Ineligible Eligible participants (n = 8) (n = 58) Declined Assessment (n = 18) (n = 40) Not randomized (n = 22)

Not depressed (n = 17) Ineligible (n = 1); refused (n = 4)

Randomization (n = 18)

Intervention group (n = 9) Discontinued Assessment after intervention (n = 2) 1 week (n = 7)

Control group (n = 9)

Assessment after 1 week (n = 9)

Depressed (n = 2) Not depressed (n = 5)

Depressed (n = 6) Not depressed (n = 3)

Assessment after 6 weeks

Assessment after 6 weeks

Not depressed (n = 7)

Depressed (n = 3) Not depressed (n = 6)

FIG. 1: Trial prole. EPDS, Edinburgh Postnatal Scale.

Depression

Analysed (n = 7)

Analysed (n = 9)

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concerns, and My attitude and relationship with my husband has changed since then.
Removing feelings of withdrawal from others

This description category comprised the womens perception of removing feelings of withdrawal from others. A common statement included: The home visits were very helpful to me because previously I did not have the will or feel encouraged to talk with or consult someone.

DISCUSSION
Results of this study demonstrate that home visits by mental health nurses can help women recover from postTABLE 1: group Demographic characteristics of participants according to Intervention (n = 7) Control (n = 9) Total (n = 16)

Characteristics

Mean age 33.86 [3.02] 33.78 [5.33] 33.81 [4.34] Parity Primiparous 7 (100) 6 (66.7) 13 (81.3) Multiparous 0 3 (33.3) 3 (18.8) Living arrangements Partner 7 (100) 6 (66.7) 13 (81.3) Parents 0 3 (33.3) 3 (18.8) Married 7 (100) 9 (100) 16 (100) Working status Employed 0 3 (33.3) 3 (18.8) Unemployed 7 (100) 6 (66.7) 13 (81.3) Educational level High school 0 4 (44.4) 4 (25.0) Up to college 7 (100) 5 (55.6) 12 (75.0) Type of delivery Spontaneous vertex 6 (85.7) 8 (88.9) 14 (87.5) Caesarean section 1 (14.3) 1 (11.1) 2 (12.5) Newborn sex Male 2 (28.6) 6 (66.7) 8 (50.0) Female 5 (71.4) 3 (33.3) 8 (50.0) Newborn birth weight 2800 [296] 3122 [473] 2981 [426] Treatment history for sterility 1 (14.3) 3 (33.3) 4 (25.0) Previous depression 2 (28.6) 4 (44.4) 6 (37.5) Results are reported as n (%) or mean [SD].

partum depression and also improve their perceived quality of life. Findings from the qualitative data suggest that women felt reassured by the visits, could relax more in their mothering role, clarify their thoughts, and improve their coping abilities. Previous studies have shown the efcacy of psychosocial interventions for post-partum depression (Brockington 2004; Dennis 2005; Lumley et al. 2004; Ray & Hoddnett 2002). In particular, home-based individual interventions by midwives (MacArthur et al. 2002), paediatric nurses (Armstrong et al. 1999; 2000; Wickberg & Hwang 1996), advanced practice nurses (Horowitz et al. 2001), or health visitors (Holden et al. 1989) reported not only efcacy in recovering from post-partum depression, but also satisfaction levels of mothers who received intervention. Cooper et al. (2003) showed that non-directive counselling and cognitive behavioural therapy by trained health visitors produced a rate of reduction in depression superior to the rates produced by specialists. Cooper et al. (2003) proposed that health visitors produced better client outcomes, because visits were made by therapists who had previous experience of home visiting. However, this explanation does not adequately explain changes after health visitors, and the efcacy of interventions by nurses or health visitors requires further analysis. Post-partum women need a great deal of energy to undertake self-care, parenting, and housework, as well as establishing an effective mothering relationship with their baby. Given the complexities of these multiple roles, home visits could be more effective in helping women deal with aspects of their life rather than requiring new mothers to attend outpatient or community-based appointments. The intervention model in the current study focused on a self-care decit framework, enabling the mental health nurse to identify and develop the womens self-care, focus on the womens daily lives, share experiences, and work on problematic life issues. The skill base of mental health nurses is also well suited to home visiting.

TABLE 2:

Changes in the Edinburgh Postnatal Depression Scale scores over the study period Intervention group (n = 7) Within-group changes in median scores Median (IQR) Median change -3.3 -4.8 P 0.027* 0.047* Median (IQR) 12.0 (10.0) 10.7 (12.0) 8.7 (9.0) Control group (n = 9) Within-group changes in median scores Median change -0.8 -2.0 P-value 0.072 0.051 Signicance of difference in changes between groups P-value 0.114 0.408

Time 1 Time 2 Time 3

9.0 (5.5) 5.5 (1.5) 5.5 (2.5)

*P < 0.05; Wilcoxon signedrank test; MannWhitney U-test; IQR, interquartile range.

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TABLE 3: Changes in quality of life scores over the study period Intervention group (n = 7) Within-group changes in median scores Median (IQR) Time 1 Time 2 Time 3 Time 1 Time 2 Time 3 Time 1 Time 2 Time 3 Time 1 Time 2 Time 3 Time 1 Time 2 Time 3 Time 1 Time 2 Time 3 18.3 (3.0) 23.0 (5.5) 24.0 (5.0) 16.3 (2.5) 19.8 (3.5) 20.0 (3.0) 9.5 (1.5) 10.3 (3.5) 11.7 (2.5) 23.3 (6.5) 27.5 (9.5) 27.0 (7.5) 5.0 (2.0) 6.4 (2.5) 6.8 (1.5) 2.9 (0.6) 3.1 (0.9) 3.4 (0.6) Median change P-value Median (IQR) Physical 19.3 (3.0) 20.0 (5.0) 20.3 (5.0) Psychological 17.0 (3.0) 16.0 (6.0) 18.0 (7.0) Social 9.0 (2.0) 9.7 (1.0) 9.6 (1.0) Environmental 22.3 (5.0) 22.3 (6.0) 23.0 (2.0) Global 5.7 (1.0) 5.6 (1.0) 5.4 (1.0) Average 2.8 (0.2) 2.8 (0.4) 2.9 (0.4) Control group (n = 9) Within-group changes in median scores Median change P-value

425

Signicance of difference in changes between groups P-value

6.0 7.0

0.018* 0.028*

-0.3 1.5

0.812 0.309

0.016* 0.012*

3.0 6.0

0.017* 0.051

-0.3 1.0

0.952 0.553

0.042* 0.071

1.0 2.3

0.084 0.045*

0.6 0.6

0.551 0.216

0.606 0.210

5.0 5.0

0.027* 0.018*

0.0 0.3

0.944 0.608

0.023* 0.005**

1.4 2.0

0.015* 0.033*

0.2 -0.4

0.890 0.453

0.016* 0.016*

0.7 0.8

0.018* 0.028*

-0.1 0.1

0.953 0.400

0.005** 0.012*

*P < 0.05; **P < 0.01; Wilcoxon sign-rank test; MannWhitney U-test; IQR, interquartile range.

Austin et al. (1999) found that mental health nurses can accurately assess womens mental states. Beeber et al. (2004) found that mental health nurses helped mothers choose strategies that were appropriate to their energy levels and interests based on systematic assessments made while building a therapeutic relationship between the nurse and the mother. Walker et al. (2000) reported that a community psychiatric nurses ability to develop strong relationships with service users was very important in providing effective mental health care. In the present study, the intervention was provided exibly according to individual needs and nurses assessments of the womens self-care level and mental state. It could be suggested that these components help led to recovery from depression. The women in the control group showed some improvement in the level of symptoms of depression over time, and reductions in the EPDS scores did not differ signicantly between the intervention and control groups. It is possible that the women recovered from depression spontaneously or that the clinical interview itself inuenced their recovery. Holden et al. (1989) indicated that women in her control group might have beneted from

taking part in the study, because they could talk about their feelings during the diagnostic interview. The fact that the three assessments were conducted by the same nurse for each woman in the current study could have helped women in the control group recover from depression, as a relationship might have formed during these interviews. However, this could also be a limitation and might explain the lack of signicant differences between the groups in terms of the EPDS scores. It is noteworthy that women receiving the intervention reported a positive effect on quality of life and this effect was maintained for 6 weeks postintervention. This might have been because of the emphasis on self-care and the womens strengths. The nurses helped and encouraged women to make decisions and enhance their daily performance. Based on the results of the qualitative data, women in the intervention group gained condence and enhanced their coping skills. These experiences could have helped them improve and maintain their quality of life. This study has several limitations, including a small sample size, the fact that the post-partum women were

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recruited within a conned area in Japan, and the severity of depression in the participants was mild or moderate. It is likely that these results cannot be generalized to other groups of post-partum women, especially those with more severe forms of post-partum depression. Therefore, further research is needed with larger samples to evaluate the effectiveness of mental health nurse interventions for women with post-partum depression. In addition, of the 867 post-partum women screened with the EPDS, 506 (58.4%) women refused to participate in the study. This high refusal rate could not be avoided as post-partum women might feel too overloaded to receive intervention and take time for home visits. However, it is possible that this high refusal rate might have biased the study results. Long-term follow-up studies are also needed to determine if the improvement in symptoms of depression and quality of life are sustained over the long term. Although the research nurses who conducted the structured clinical interview were blinded to the subsequent group allocation, it would be difcult to be completely unaware of group assignments because of the nature of the study. Although it is clear that the support through home visits was convenient for post-partum women, this treatment method is costly. The present study demonstrated the effectiveness in reducing symptoms of depression and improving quality of life with only four home visits. Consequently, it might be valid for mental health nurses to be included as part of routine post-partum services. In addition, in Japan, few mental health nurses have worked in community mental health, especially in the primary care setting, and during nursing school, students have little opportunity to learn about post-partum mental health. Thus, changes to nursing education are needed regarding post-partum issues and different models of care delivery.

Yamaoto for their helpful advice. This research was supported by the Grant-in-Aid for Scientic Research from the Japan Society for the Promotion of Science, and a grant from the University of Hyogo, Hyogo, Japan.

REFERENCES
Armstrong, K. L., Fraser, J. A., Dadds, M. R. & Morris, J. (1999). A randomized, controlled trial of nurse home visiting to vulnerable families with newborns. Journal of Paediatric Child Health, 35 (3), 237244. Armstrong, K. L., Fraser, J. A., Dadds, M. R. & Morris, J. (2000). Promoting secure attachment, maternal mood and child health in a vulnerable population: A randomized controlled trial. Journal of Paediatric Child Health, 36, 555562. Austin, M. P., Dudley, M., Launders, C., Dixon, C. & McCartney-Bourne, F. (1999). Description and evaluation of a domiciliary perinatal mental health service focusing on early intervention. Archives of Womens Mental Health, 2, 169173. Beck, C. T. (1992). The lived experience of postpartum depression: A phenomenological study. Nursing Research, 41 (3), 166171. Beck, C. T. (1993). Teetering on the edge: A substantive theory of postpartum depression. Nursing Research, 42 (1), 4248. Beck, C. T. (1996). Postpartum depressed mothers experiences interacting with their children. Nursing Research, 45 (2), 98104. Beck, C. T. (1998). The effects of postpartum depression on child development: A meta-analysis. Archives of Psychiatric Nursing, 12 (1), 1220. Beck, C. T. (1999). Maternal depression and child behavior problems: A meta-analysis. Journal of Advanced Nursing, 29 (3), 623629. Beeber, L. S., Holditch-Davis, D., Belyea, M. J. & Funk, S. G. (2004). In-home intervention for depressive symptoms with low-income mothers of infants and toddlers in the United States. Health Care for Women International, 25, 561580. Brockington, I. (2004). Postpartum psychiatric disorders. The Lancet, 363, 303310. Chan, S. W., Levy, V., Chungm, T. K. H. & Lee, D. (2002). A qualitative study of the experiences of group of Hong Kong Chinese women diagnosed with postnatal depression. Journal of Advanced Nursing, 39 (6), 571579. Cooper, P. J. & Murray, L. (1995). Course and recurrence of postnatal depression: Evidence for the specicity of the diagnostic concept. British Journal of Psychiatry, 166, 191195. Cooper, P. J., Murray, L., Wilson, A. & Romaniuk, H. (2003). Controlled trial of short- and long-term effect of psychological treatment of post-partum depression 1: Impact on maternal mood. British Journal of Psychiatry, 182, 412419. Cox, J. L., Holden, J. M. & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh postnatal depression scale. British Journal of Psychiatry, 150, 782786.

CONCLUSION
These results indicate that home visits by mental health nurses for women with post-partum depression had signicant positive effects on quality of life and ameliorated symptoms of depression. In post-partum services, mental health nurses could support mothers with depression effectively through care that focuses on the womens daily life and self-care, accurately assessing womens mental status and energy levels, and building relationships.

ACKNOWLEDGEMENT
The author is grateful to the women and nurses who participated in this study and to Dr Hiroko Minami, Dr Tadaharu Okano, Dr Hirofumi Takagi, and Dr Aiko

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