the influence of culture on the development and detection of postpartum depression cindy-lee dennis,...
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The Influence of Culture on the Development and Detection of Postpartum Depression
Cindy-Lee Dennis, RN, PhDAssistant Professor, Faculty of Nursing
CIHR New InvestigatorCareer Scientist, Ontario Ministry of Health
Dr.Cindy-Lee Dennis
What are immigrant mothers at increased risk for postpartum depression?
Why does postpartum depression often remain undetected?
What is screening?
What tools can health professionals use to detect postpartum depression?
Recommendations for detecting depressive Symptoms
Dr.Cindy-Lee Dennis
Childbirth represents for women a time of great
vulnerability to become mentally unwell, with
postpartum mood disorders representing the
most frequent form of maternal morbidity
following delivery
Dr.Cindy-Lee Dennis
These affective disorders following childbirth
range in severity from the early maternity blues
to postpartum psychosis, a serious state affecting
less than 1% of mothers
Dr.Cindy-Lee Dennis
Within this group of disorders is postpartum depression, a condition often exhibiting the disabling symptoms of dysphoria, emotional lability, insomnia, confusion, anxiety, guilt, and suicidal ideation.
Frequently exacerbating these indicators are low self-esteem, inability to cope, feelings of incompetence, and loneliness.
Dr.Cindy-Lee Dennis
The inception rate is greatest in the first 12
weeks postpartum with duration frequently
dependent on severity and time to onset of
treatment
Postpartum depression is a major public health
issue for many women from diverse cultures
Dr.Cindy-Lee Dennis
Longitudinal and epidemiological studies have yielded varying prevalence rates, ranging from 3% to more than 25% of women in the first year following delivery
These rates fluctuate due to sampling, timing of assessment, differing diagnostic criteria, and whether the studies were retrospective or prospective (6- to 10-fold higher)
Dr.Cindy-Lee Dennis
A meta-analysis of 59 studies reported an overall prevalence of postpartum depression to be 13%
It is noteworthy that the absolute difference in estimates between self-report assessments and diagnostic interviews was small
Dr.Cindy-Lee Dennis
Risk Factors (Beck, 2001)
Prenatal depression Childcare stress Life stress Lack of social support Prenatal anxiety Maternity blues Marital dissatisfaction Previous history of depression Low self-esteem Low socio-economic status Marital status Unwanted/unplanned pregnancy
Dr.Cindy-Lee Dennis
However, preliminary research suggests that
immigrant mothers from diverse cultures may be
at higher risk to develop postpartum depression
Dr.Cindy-Lee Dennis
Postdoctoral Research Fellowship
UBC, Faculty of Medicine, Dept. Health Care & Epidemiology
Population-based study - 645 mothers completed questionnaires at 1, 4, and 8 weeks postpartum
Dr.Cindy-Lee Dennis
Edinburgh Postnatal Depression Scale (EPDS)
10-item self-report instrument
Designed specifically to assess depressive
symptoms in new mothers
Cut-off >12 = confirm postpartum depression
Cut-off > 9 = community-based screening
Translated into diverse languages
Dr.Cindy-Lee Dennis
Sample Characteristics
Mean age was 28.5 years (SD = 5.0) 89% Caucasian 90% married or common-law 39% high school or less, 38% college/trade
education, 21% university degree Income: 36% < $30,000, 31% > $80,000 44% primiparous 74% vaginal delivery 69% discharged home within 48 hours
Dr.Cindy-Lee Dennis
Question
Who is at risk for depressive symptoms in the immediate postpartum period?
A multifactorial predictive model was developed using sequential logistic regression analysis
The outcome was an EPDS score > 9 at 1-week postpartum
Dr.Cindy-Lee Dennis
Socio-Demographic Factors1. Marital status
2. Age
3. Education
4. Ethnicity
5. Immigration during the last five years
6. Household income
7. Ability to manage with income
8. Access to transportation
9. Suitable housing
Dr.Cindy-Lee Dennis
Biological/Psychological Factors
1. Vulnerable personality
2. Self-Esteem
3. Premenstrual symptoms
4. Maternal psychiatric history
5. Family psychiatric history
6. History of postpartum depression
Dr.Cindy-Lee Dennis
Pregnancy Factors
1. Infertility problems
2. Planned pregnancy
3. Mother’s feelings about pregnancy
4. Partner’s feelings about pregnancy
5. Pregnancy complications
Dr.Cindy-Lee Dennis
Life Stressors
1. Life events (past 12 months)
2. Job stress
3. Worrying about returning to work
4. Satisfaction with job
Dr.Cindy-Lee Dennis
Substance Abuse and Violence
1. Use of alcohol and drugs by the mother or her partner
2. History of physical or sexual abuse
3. Fear of partner
4. History of physical abuse as a child
5. Physical abuse directed towards the subject’s mother by her father
6. Interaction with child protection services
Dr.Cindy-Lee Dennis
Social Support
1. Global Support
2. Relationship-Specific Support from:
– Partner
– Mother
– Mother-in-law
– Other women with children
Dr.Cindy-Lee Dennis
Obstetrical Factors
1. Induction of labour
2. Mode of delivery
3. Satisfied with pain management
4. Control during labour
5. Labour complications
Dr.Cindy-Lee Dennis
Maternal Adjustment
1. Ready for hospital discharge
2. Infant feeding method
3. Satisfaction with infant feeding method
Dr.Cindy-Lee Dennis
In the multivariate analysis, significant variables were tested and retained in the model if the p-value for the beta-estimate was 0.05 or less
Variables were entered into the model in the following chronological order: socio-demographic, biological/psychological, pregnancy, life stressors, substance abuse/violence, social support, obstetric, and maternal adjustment.
Dr.Cindy-Lee Dennis
Risk Factor Beta OR 95% CI
Immigrated within last five years
1.60 4.94 1.00-24.8
History of depression before pregnancy
0.60 1.82 1.05-3.16
Vulnerable personality 0.20 1.21 1.13-1.31
Life stressors 0.12 1.12 1.01-1.24
Pregnancy-induced hypertension
1.28 3.62 1.05-9.74
Global support -.04 0.96 0.93-0.99
Satisfaction with infant feeding method
.83 2.29 1.13-4.64
Ready for hospital discharged 1.33 3.78 1.40-10.19
Dr.Cindy-Lee Dennis
Dennis, C-L., Janssen, P., & Singer, J. (2004). Identifying Women At-Risk for Postpartum Depression in the Immediate Postpartum Period: Development of a Multifactorial Predictive Model. Acta Psychiatrica Scandinavica, 110, 338-346
Dr.Cindy-Lee Dennis
Among the few studies that have examined immigration, most have also found this variable to be a significant factor
1. Danaci, A. E., Dinc, G., Deveci, A., Sen, F. S., & Icelli, I. (2002). Postnatal depression in turkey: epidemiological and cultural aspects. Social Psychiatry & Psychiatric Epidemiology, 37(3), 125-129.
2. Dankner, R., Goldberg, R. P., Fisch, R. Z., & Crum, R. M. (2000). Cultural elements of postpartum depression. A study of 327 Jewish Jerusalem women. Journal of Reproductive Medicine, 45(2), 97-104.
3. Glasser, S., Barell, V., Shoham, A., Ziv, A., Boyko, V., Lusky, A., et al. (1998). Prospective study of postpartum depression in an Israeli cohort: prevalence, incidence and demographic risk factors. Journal of Psychosomatic Obstetrics & Gynecology, 19(3), 155-164.
4. Zelkowitz, P., & Milet, T. H. (1995). Screening for post-partum depression in a community sample. Canadian Journal of Psychiatry, 40(2), 80-86.
Dr.Cindy-Lee Dennis
Unfortunately, scant research has been
conducted as to why these women are at-risk
postpartum depression
Why are immigrant women at risk for PPD?
Dr.Cindy-Lee Dennis
Investigations with general non-postpartum
immigrant populations have clearly
demonstrated a link between the acculturation
process and psychological problems
Dr.Cindy-Lee Dennis
When individuals interface with a new host
society, they confront many challenges,
including adjusting to a new language,
different customs and norms for social
interactions, unfamiliar rules and laws, and in
some cases extreme lifestyle changes (e.g.,
rural to urban)
Dr.Cindy-Lee Dennis
Acculturation refers to the process of
adjusting to these life modifications, and
depending on the disparity between the two
cultures, acculturative stress is a common
outcome resulting frequently in an increased
risk for depression
Dr.Cindy-Lee Dennis
While considerable attention has been paid to the
importance of acculturative stress on depression
among non-postpartum immigrant populations
and stressful life events on maternal mood, the
relationship between acculturative stress and
postpartum depression has not been explored
Dr.Cindy-Lee Dennis
Research also suggests factors may have a protective effect on acculturative stress, including the provision of social support and socio-economic status
This is particularly salient for postpartum depression, given that studies clearly suggest social deficiencies increase the risk of postpartum depression
Dr.Cindy-Lee Dennis
In addition to enhancing social support, another factor that may have a protective effect on the development of postpartum depression is traditional postpartum rituals
For example, in many cultures special practices and customs serve to impose structure and meaning in the perinatal period and promote the successful transition to motherhood (Stuchbery, Matthey, & Barnett, 1998)
Dr.Cindy-Lee Dennis
These postpartum rituals have been examined in
varying degrees among many cultures (e.g.,
Arabic, Chinese, Japanese, Malaysian, Taiwanese,
Thai, etc. ) and frequently last
between 30 to 40 days
Dr.Cindy-Lee Dennis
While several studies provide evidence that
traditional postpartum rituals are followed by the
majority of women in their native country,
limited research has been conducted related to
the practice of these rituals post-migration
Dr.Cindy-Lee Dennis
Current Research Initiative
Systematic Review of
Traditional Postpartum Practices
Dr. Cindy-Lee Dennis Dr. Lori Ross Dr. Sarah Romans Dr. Gail Robinson Dr. Ken Fung
Dr.Cindy-Lee Dennis
Traditional postpartum rituals among indigenous/native mothers (including rationale for practices):
1. organized support (includes who, where, what activities, etc.)
2. dietary practices
3. restricted physical activities
4. hygiene practices
5. celebrations (e.g., naming baby)
6. other rituals
Dr.Cindy-Lee Dennis
Among chinese mothers the traditional rite of “Tso-Yueh-Tzu”, translated as ‘doing the month’, is concerned with beliefs and practices associated with the postpartum period
When doing the month, women are required to stay indoors and to follow specific dietary, hygiene, and physical activity restrictions for 4 weeks to promote recuperation
Additionally, someone (usually a female family member) assumes most of the infant care and household responsibilities
Example
Dr.Cindy-Lee Dennis
This traditional practice has been investigated in a number of studies and all suggest that many Chinese women still follow the practice and believe that it will improve their health (Cheung, 1997; Davis, 2001; Holroyd, Katie, Chun, & Ha, 1997; Lee et al., 1998)
However, resent research studying Hong Kong mothers found environmental constraints and difficulties in following the proscriptions of the traditional practices and questioned how women could adapt the ritual to fit with modern life (Leung, Arthur, & Martinson, 2005)
Dr.Cindy-Lee Dennis
Similarly, one Australian study found that 18% of immigrant Chinese mothers felt ambivalent about traditional practices and that the reason they followed the practice was to please their in-laws (Matthey, Panasetis, & Barnett, 2002)
Furthermore, two studies suggest adherence to these traditional practices among native and immigrant Chinese mothers may not be protective against the onset of PPD (Leung, Arthur, & Martinson, 2005; Matthey, Panasetis, & Barnett, 2002)
Dr.Cindy-Lee Dennis
While there are many variables involved in the practice of ‘doing the month’ that may have potential health benefits, research suggests that one salutary aspect may be the provision of organized support and that PPD may be prevented
However, it is unknown whether it indeed does have a potential protective effect or whether these rituals simply delay the development of PPD, as preliminary research with Hong Kong Chinese women suggests
Dr.Cindy-Lee Dennis
Postpartum Practices and Depression Prevalences:
Technocentric and Ethnokinship Cultural Perspectives
Posmontier, B., & Horowitz, J. A. (2004). Postpartum practices and depression prevalences: technocentric and ethnokinship cultural perspectives. Journal of Transcultural Nursing, 15(1), 34-43.
Dr.Cindy-Lee Dennis
Technocentric Cultures which use technology to monitor new
mothers The infant is the primary focus in the immediate
postpartum period Potential danger 24-48 hours Maternal-infant separation Mother discharged home to a social system that
does not have formalized traditions or norms Technology is valued over social networks Canada, US, UK, Western Europe, Australia
Dr.Cindy-Lee Dennis
Ethnokinship
Cultures in which the performance of social support rituals by family networks are the primary focus in the immediate and later postpartum period
While advanced technology is used to promote safe and optimum postpartum outcomes the family social supports retains primary importance
Korean, Chinese, Japanese, Hmong, Mexican, African, Arabic, Amish
Dr.Cindy-Lee Dennis
Postpartum support structures Mandated rest and assistance with household
tasks Maternal vulnerability Social seclusion Recognition of role transition
Dr.Cindy-Lee Dennis
Cultural PPD Risk Factors
Acculturative stress Traditional postpartum practices
Why does postpartum depression often remain undetected?
Dr.Cindy-Lee Dennis
The lack of detection is not just a health professional issue that can be dealt with by just screening
Women do not proactively seek help
Dennis, C-L., & Chung-Lee, L. (submitted). A review of postpartum depression help-seeking behaviours and treatment preferences. Birth.
Dr.Cindy-Lee Dennis
Maternal Barriers
Reluctant to obtain professional assistance
Unwilling to disclose emotional problems especially depression
Popular myth equates motherhood with happiness
Dr.Cindy-Lee Dennis
Do not know where to obtain assistance
Unaware of treatment options
Perceive health professional role to address physical symptoms not emotional problems
Somatization - women translate emotional distress into physical symptoms
Dr.Cindy-Lee Dennis
Lack knowledge about PPD
Not aware they are suffering from the condition
Deny and minimize symptoms
Difficulty understanding the problems they are experiencing
– assume struggles are normal for mothers– reasonable response to adversity
Dr.Cindy-Lee Dennis
Conversely, some women recognize depression but fear:
– having child taken aware
– being labelled mentally ill
– not fulfilling role as mother
– obtaining a more serious mental diagnosis
Dr.Cindy-Lee Dennis
Also, depression implies weakness or perceived failure
Family members may discourage help seeking – in some cultures it is unacceptable to admit to depressive symptoms
Some family member lack knowledge about PPD
Dr.Cindy-Lee Dennis
Health Professional Barriers
Limited training in the assessment and management of PPD
Feel uncertain about how to effectively assist therefore reluctant to raise such issues
Dr.Cindy-Lee Dennis
Normalize symptoms and dismiss as self-limiting
Mothers obtaining professional assistance felt disappointment, frustration, humiliation, and anger
Patronizing attitudes – increased feelings of worthlessness and guilt in inability to cope
Dr.Cindy-Lee Dennis
Insufficient time in consultations
Prefer to prescribe medication that alleviated symptoms but reinforced feelings of inadequacy
Not referred to secondary services
Language barriers
Dr.Cindy-Lee Dennis
Health Service Utilization
Culture constitutes an important context for affective conditions as shared beliefs, attitudes, and norms for emotional responses influences how mothers experience depression
Culture also determines help-seeking behaviours and health service utilization
Dr.Cindy-Lee Dennis
It is well documented that in Canada, ethnic minorities are less likely than Caucasians to seek mental health treatment and they often delay treatment until symptoms are more severe
They are also less likely to seek treatment from mental health specialists, instead turning more often to primary care or informal sources such as clergy, traditional healers, and family and friends
Dr.Cindy-Lee Dennis
While health professionals increasingly
emphasize the need for cultural competence and
the problem of health service barriers and
utilization inequities, no research has been
conducted with immigrant women related to
specific postpartum depression help-seeking
barriers and health service utilization
Dr.Cindy-Lee Dennis
Clinical Implications:
Strategies For Caring For Mothers From Different Cultures
Dr.Cindy-Lee Dennis
Education about PPD is important for women as it could enable earlier recognition and help-seeking
Information about services and health professional’s roles may be particularly effective in specific cultural groups if it were aimed at family members as well as the mothers
Educational programs could be conducted across the perinatal period with a focus on assisting the family in understanding the stresses related to motherhood and identifying specific strategies to help the mother cope with these challenges
Dr.Cindy-Lee Dennis
Understanding of the different ways in which mothers conceptualize, explain, and report symptoms of depression
The term ‘postpartum depression’ may not be acceptable to many mothers and an alternative approach to recognition and management may be required
This may involve the use of symptom and context-based terms such as tension, weakness, and difficulties in one’s relationship at home
Dr.Cindy-Lee Dennis
Health professionals should also be aware of traditional postpartum practices and understand the rationale behind such practices
Meaning of traditional practices to the mother
Preliminary research suggests that devaluing traditional practices based on a woman’s cultural group could mean devaluing the mother as a person
Dr.Cindy-Lee Dennis
Treatment Preferences
Pharmacological Interventions
Women are often reluctant to take antidepressant medication even after receiving education
Fear of addiction Potential side-effects or harm related to long-
term use Concerns influenced medication compliance
Dr.Cindy-Lee Dennis
Opportunity to Talk about FeelingsWomen want:1. to be given permission to talk in-depth about
their feelings, including ambivalent and difficult feelings
2. to talk with a non-judgmental person who will spend time listening to them, take them seriously, and understand and accept them for who they are
3. recognition that there is a problem and reassurance that other mothers experience similar feelings and that they will get better
Dr.Cindy-Lee Dennis
Provision of Peer Support
The ways in which individual women interpreted, negotiated, and experienced social norms of motherhood depends in part on their interpersonal relationships with other mothers
Support from other women with children was perceived as particularly important for recovery
Dr.Cindy-Lee Dennis
Among immigrant and ethnic minority women:
Support groups facilitated activities such as shopping and learning English
In a phenomenological study with Middle Eastern women living in Australia, ‘Arabic community centers’ provided immigrant women with diverse activities, such as sewing and cooking, that were aimed at relieving their stress by taking them out of their houses and enabling them to interact with other women (Nahas , 1999)
Dr.Cindy-Lee Dennis
Depressed mothers using these centers reported that they could cope much better when they returned home to meet their husband and resume their traditional roles
Similar results with immigrant mothers living in the UK (Templeton , 2003)
Women attending a group felt it was a break from housework and childcare responsibilities and that it allowed them to relax and meet people
Dr.Cindy-Lee Dennis
Meaning of Care
Dr.Cindy-Lee Dennis
In a phenomenological study involving US
mothers, seven themes emerged that illustrated
nurses' caring for mothers experiencing
postpartum depression and promoted satisfaction
with care received (Beck)
US Mothers
Dr.Cindy-Lee Dennis
1. Having sufficient knowledge about postpartum depression
2. Using astute observation and intuition to make quick, correct diagnoses
3. Providing hope that the mothers' depression will come to an end
4. Readily sharing their time
5. Making appropriate referrals for the right path to recovery
6. Providing continuity of care
7. Understanding what the mothers were experiencing
Dr.Cindy-Lee Dennis
In a qualitative study of 22 Jordanian women
living in Australia who had suffered from
postpartum depression, three themes focusing on
the meaning of care were discussed (Nahas , 1999)
Jordanian Mothers
Dr.Cindy-Lee Dennis
1. Care meant strong family support and kinship during the postpartum period
2. Care included preservation of Jordanian childbearing customs as expressed in the celebration of the birth of the baby
3. Care was being allowed to fulfilling traditional gender roles as mother and wife
Dr.Cindy-Lee Dennis
Health professionals facilitating treatment services should address these issues and ensure that interpreters are available for those women who do not speak or understand English
Health professionals need to recognize and take into account mothers’ own explanations of their problem and their ideas concerning what might constitute an appropriate treatment
Dr.Cindy-Lee Dennis
Be aware of acculturative stress Acknowledge traditional postpartum rituals Address barriers to seeking help Provide culturally sensitive treatment based on
maternal perceptions
Improve detection and treatment of PPD
What is Screening?
Dr.Cindy-Lee Dennis
Screening A systematic use of tools or procedures applied
to a defined population (e.g., new mothers)
Purpose is to detect an unrecognized disorder or condition in individuals who do not yet perceive that they are at risk of, or suspect that they are affected by, a condition or its complications
Dr.Cindy-Lee Dennis
Screening tools do not diagnose a condition
Only identifies individuals who are:– at risk of developing the condition– are displaying potential symptoms of the
condition
In the case of PPD, health professionals could use screening procedures to identify women with depressive symptoms who may require additional intervention
Dr.Cindy-Lee Dennis
Screening has the potential to improve the quality of life through early diagnosis of a serious condition
Screening is not perfect– false positive
individuals wrongly reported to have the condition
– false negative individuals wrongly reported as not having the
condition
What tools can health professionals use to detect
postpartum depression?
Dr.Cindy-Lee Dennis
The diagnosis of PPD can only be accomplished through the application of diagnostic criteria such as the popular and progressively evolving Diagnostic and Statistical Manual [e.g., DSM-IV]
Measures used to assess for depressive symptoms include standardized interviews and self-report questionnaires
Dr.Cindy-Lee Dennis
Self-Report
The most common and clinically useful way to screen - administer a self-report questionnaire
Women rate the frequency or severity of their own depressive symptoms
Dr.Cindy-Lee Dennis
Edinburgh Postnatal Depression Scale (EPDS) The most widely used instrument to assess for
PPD and identify high-risk mothers
Advantage It has been translated into various languages and
tested in samples from a variety of countries
Disadvantage Most investigations involve Caucasian or
homogenous samples in native countries
Few studies have psychometrically assessed the EPDS using clinical diagnostic interviews among recently immigrated women
Dr.Cindy-Lee Dennis
While screening procedures may significantly assist in the detection of PPD, these tasks are complicated when assessing women from different cultural groups
For example, somatization may be a prominent expression of depression among Asian and African cultures, while complaints of sadness and feelings of guilt are more characteristic of depression in Western cultures
Accurate Assessment and Detection
Dr.Cindy-Lee Dennis
Unresolved problems related to appropriate cut-off scores for specific ethnic groups
For example, while a cut-off score of 12/13 has been repeatedly validated and recommended for detecting PPD and 9/10 for community based screening, validation studies have highlighted that scores from translated versions should be interpreted cautiously as different cut-off points have been suggested
Dr.Cindy-Lee Dennis
In particular, Lee et al. recommended a cut-off of 9/10 was most appropriate at 6 weeks postpartum for detecting PPD in a Hong Kong population
Okano et al. reported that a cut-off of 8/9 was suitable for screening Japanese mothers
In an Australian study of Vietnamese and Arabic mothers, fewer Vietnamese mothers met the criteria for depression
However, detailed comparisons between EPDS and Diagnostic Interview Schedule (a diagnostic measure) questions suggested that these lower rates were possibly due to the social undesirability of verbally reporting negative emotions and a cut-off of 9/10 was suggested for Vietnamese women
Dr.Cindy-Lee Dennis
Similar response patterns were found by Lee in their Hong Kong study
It is possible that these Chinese women, like their Vietnamese counterparts, were reluctant to concede unhappiness or distress in the early postpartum period to an interviewer
However, the women seemed less constrained in responding to a self-report questionnaire
Dr.Cindy-Lee Dennis
In contrast, Yoshida found similar depression rates in Japanese women residing in England and Japan using a clinical diagnostic interview
However, depression was not detected when the translated EPDS was used as a screening instrument
In particular, a 12/13 cut-off resulted in a sensitivity of zero, rendering the researchers to conclude that Japanese women may be reluctant to disclose depressive symptoms via a self-report measure
They also commented that the difference might be due to the exclusion of somatic symptoms in the EPDS since Japanese women tend to refer to physical problems and concerns about their infant rather than expressing feelings of low mood directly
Dr.Cindy-Lee Dennis
These results suggest that if health professionals are to implement accurate yet culturally-appropriate screening procedures, additional research is required among diverse cultural groups to determine:
1. PPD prevalence rates
2. Patterns of inception
3. EPDS accuracy
Dr.Cindy-Lee Dennis
A Few Points to Consider When Using the EPDS
Some researchers and clinicians have identified common misperceptions about how to use and interpret PPD screening tools
Dr.Cindy-Lee Dennis
“A score below a cut-off confirms that the mother has no mental health disorder.”
Using the EPDS, it is unlikely that a mother scoring below 10 has clinically significant levels of depression
However, it is possible, particularly when the tool is administered to multicultural populations
Furthermore, health professionals need to recognize that a low score on the EPDS does not rule out symptoms of other mental health conditions or problems of concern (e.g., anxiety disorders or psychosis)
Dr.Cindy-Lee Dennis
“The screening tool makes the decision to treat, so a score above the cut-off point means a referral to a service provider.”
An EPDS score is only one factor to consider when deciding on whether or not to initiate treatment and preventive strategies
Clinical judgment also plays a critical role
Finally, it is important that the decision be a collaborative one between the mother and her health professional
When would be the most effective time to screen for postpartum
depression?
Dr.Cindy-Lee Dennis
Antenatal Screening An excellent systematic review (Austin & Lumley,
2003) summarized 16 studies that included antenatal screening
No screening instrument met the criteria for
routine application in the antenatal period
The unacceptably low positive predictive
values in all these studies make it difficult
to recommend the use of screening tools in
routine antenatal care
Dr.Cindy-Lee Dennis
However, approximately 12% of women are depressed during pregnancy, and the EPDS can detect depressive symptoms antenatally
Therefore, when the health care system criteria described are met, a health unit or organization might decide to use the EPDS to identify pregnant women for current depression, so that these women receive treatment as soon as possible
So long as the goal is to detect current rather than future depression, the EPDS can be useful during the antenatal period
Dr.Cindy-Lee Dennis
Postnatal Screening Traditionally, experts have proposed that
screening tools be administered between 6 to 8 weeks postpartum
The rationale for waiting to screen until 6 weeks postpartum is that the maternity blues will have resolved by this time
Screening earlier in the postpartum period might result in a high false positive rate
Dr.Cindy-Lee Dennis
In the Canadian health care system, a benefit of screening at approximately 6 weeks postpartum is that most women will attend a follow-up appointment with their obstetrical health professional around this time, and therefore may be relatively easy to access
Dr.Cindy-Lee Dennis
Immediate Postpartum Period
More recently, some researchers have suggested that even despite the high false positive rate, screening during the immediate postpartum period (i.e., the first 2 weeks postpartum) may be preferred to waiting until 6 to 8 weeks postpartum
Strong research evidence suggests that low maternal mood in the immediate postpartum period is highly predictive of the development of PPD
Dr.Cindy-Lee Dennis
Disadvantage
A significant proportion of the women who screen positive for depression at 1 to 2 weeks postpartum may not meet diagnostic criteria for depression
Women who do not actually require treatment for PPD might consume substantial resources
Dr.Cindy-Lee Dennis
Two-Stage Screening
Where resources permit, a two-stage screening process, in which mothers who score positive during the first screening assessment are re-administer the EPDS again later, may be the most effective way to implement a screening program
Research has not determined exactly how much later to administer the screening tool again
RNAO Best Practice
Guideline
Dr.Cindy-Lee Dennis
Development Panel Members
Cindy-Lee Dennis (Team Leader)
Stephanie Lappan-Gracon (Program Coordinator)
Sue Bookey-Bassett Donna Bottomley
Barbara Bowles Judi De Boeck
Marilyn Evans Denise Hebert
JoAnne Hunter Elizabeth McGoarty
Karen McQueen Phyllis Montgomery
Lori Ross Marcia Starkman
Sharon Thompson Ulla Wise
Bonnie Wooten
Dr.Cindy-Lee Dennis
Purpose and Scope
Confirmation, prevention and treatment of mothers with depressive symptoms in the first postpartum year
Dr.Cindy-Lee Dennis
Recommendations forDetecting Depressive Symptoms
(application to mothers from different cultures)
Dr.Cindy-Lee Dennis
EPDS is the recommended self-report tool to confirm depressive symptoms in postpartum mothers
The EPDS can be administered anytime throughout the postpartum period (birth to 12 months) to confirm depressive symptoms
Dr.Cindy-Lee Dennis
Encourage mothers to complete the EPDS by themselves in privacy
Dr.Cindy-Lee Dennis
An EPDS cut-off score greater than 12 may be used to determine depressive symptoms among English-speaking women in the postpartum period. This cut-off criterion should be interpreted cautiously with mothers who (1) are non-English speaking, (2) use English as a second language, and/or (3) from diverse cultures
Dr.Cindy-Lee Dennis
The EPDS must be interpreted in combination with clinical judgment to confirm mothers with depressive symptoms
Dr.Cindy-Lee Dennis
Provide immediate assessment for self harm ideation/behaviour when a mother scores positive (e.g from 1 to 3) on the EPDS self harm item number 10
Dr.Cindy-Lee Dennis
Many unanswered questions remain
Dr.Cindy-Lee Dennis
New Mothers in a New Country
Understanding Postpartum Depression among Recent Immigrant and Canadian-
Born Chinese Women
Principal Investigator: Dr. C-L Dennis
Dr.Cindy-Lee Dennis
Research Objectives
1. To determine the prevalence of postpartum depression (PPD), patterns of inception, and psychometric properties of the Edinburgh Postnatal Depression Scale (EPDS) among recent immigrant Chinese mothers
2. To examine the relationships between recent immigrant status, PPD, acculturation, acculturative stress, social support, income, and the practice of traditional postpartum rituals
Dr.Cindy-Lee Dennis
3. To determine patterns of PPD help-seeking behaviours and barriers to health services among recent immigrant Chinese mothers
Dr.Cindy-Lee Dennis
Study Design A longitudinal design where recently immigrated
Chinese mothers will be followed for the first year postpartum
A Canadian-born cohort of Chinese mothers will also be followed as a control group for comparisons
Following a comprehensive recruitment plan, a research assistant (matched on maternal language ability) via telephone will provide all potentially eligible women with a detailed study explanation and ensure eligibility
Dr.Cindy-Lee Dennis
Participating mothers will complete baseline information within 4 weeks postpartum
All mothers will be followed–up at 12, 24 and 52 weeks postpartum via telephone by trained research assistants
Dr.Cindy-Lee Dennis
The study results will make substantive contributions in seven areas:
1. Provide information about PPD prevalence and inception rates among recently immigrated and Canadian-born Chinese women
2. Establish the sensitivity and specificity of the Edinburgh Postnatal Depression Scale (the most widely-used international measure to assess depressive symptoms in postpartum women) in detecting PPD among these Chinese mothers
3. Advance our understanding of the relationship between recent immigrant status, the acculturation process, and PPD
Dr.Cindy-Lee Dennis
4. Determine which traditional postpartum rituals are maintained post-migration and the effect of these practices on the development of PPD
5. Investigate health service utilization barriers and help-seeking behaviours related to PPD
6. Promote cultural sensitivity among health professionals
7. Guide the development of a randomized controlled trial to evaluate a culturally-sensitive PPD intervention
Dr.Cindy-Lee Dennis
Postpartum Depression Peer Support Trial
RCT to evaluate the effect of telephone-based peer (mother-to-mother) support on the prevention of PPD among high-risk mothers
Screening for high-risk mothers across the province
– Peel - Windsor– Halton - Ottawa– York - Sudbury– Toronto
Dr.Cindy-Lee Dennis
Relevance for Screening
PPD prevalence rates for a multicultural population
Accuracy of screening for PPD at 1 week postpartum
Maternal acceptance to screening Inability to screen due to language barriers Cost of screening for PPD Referral of mothers with clinical depression at
12 weeks postpartum Reassessment of these mothers at 24 weeks to
determine treatment preference and effectiveness
Questions