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The Influence of Culture on the Development and Detection of Postpartum Depression


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Title: The Influence of Culture on the Development and Detection of Postpartum Depression

The Influence of Culture on the Development and
Detection of Postpartum Depression
  • Cindy-Lee Dennis, RN, PhD
  • Assistant Professor, Faculty of Nursing
  • CIHR New Investigator
  • Career Scientist, Ontario Ministry of Health

  • What are immigrant mothers at increased risk for
    postpartum depression?
  • Why does postpartum depression often remain
  • What is screening?
  • What tools can health professionals use to detect
    postpartum depression?
  • Recommendations for detecting depressive Symptoms

  • 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

  • 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

  • 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.

  • The inception rate is greatest in the first 12
    weeks postpartum with duration frequently
    dependent on severity and time to onset of
  • Postpartum depression is a major public health
    issue for many women from diverse cultures

  • 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)

  • 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

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

  • However, preliminary research suggests that
    immigrant mothers from diverse cultures may be at
    higher risk to develop postpartum depression

Postdoctoral Research Fellowship
  • UBC, Faculty of Medicine, Dept. Health Care
  • Population-based study - 645 mothers completed
    questionnaires at 1, 4, and 8 weeks postpartum

Edinburgh Postnatal Depression Scale (EPDS)
  • 10-item self-report instrument
  • Designed specifically to assess depressive
    symptoms in new mothers
  • Cut-off gt12 confirm postpartum depression
  • Cut-off gt 9 community-based screening
  • Translated into diverse languages

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 lt 30,000, 31 gt 80,000
  • 44 primiparous
  • 74 vaginal delivery
  • 69 discharged home within 48 hours

  • 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 gt 9 at 1-week

Socio-Demographic Factors
  1. 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

Biological/Psychological Factors
  • Vulnerable personality
  • Self-Esteem
  • Premenstrual symptoms
  • Maternal psychiatric history
  • Family psychiatric history
  • History of postpartum depression

Pregnancy Factors
  • Infertility problems
  • Planned pregnancy
  • Mothers feelings about pregnancy
  • Partners feelings about pregnancy
  • Pregnancy complications

Life Stressors
  • Life events (past 12 months)
  • Job stress
  • Worrying about returning to work
  • Satisfaction with job

Substance Abuse and Violence
  • Use of alcohol and drugs by the mother or her
  • History of physical or sexual abuse
  • Fear of partner
  • History of physical abuse as a child
  • Physical abuse directed towards the subjects
    mother by her father
  • Interaction with child protection services

Social Support
  • Global Support
  • Relationship-Specific Support from
  • Partner
  • Mother
  • Mother-in-law
  • Other women with children

Obstetrical Factors
  • Induction of labour
  • Mode of delivery
  • Satisfied with pain management
  • Control during labour
  • Labour complications

Maternal Adjustment
  • Ready for hospital discharge
  • Infant feeding method
  • Satisfaction with infant feeding method

  • 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
  • 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.

(No Transcript)
  • 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

  • Among the few studies that have examined
    immigration, most have also found this variable
    to be a significant factor
  • 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.
  • 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.
  • 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.
  • Zelkowitz, P., Milet, T. H. (1995). Screening
    for post-partum depression in a community sample.
    Canadian Journal of Psychiatry, 40(2), 80-86.

  • Unfortunately, scant research has been conducted
    as to why these women are at-risk postpartum

Why are immigrant women at risk for PPD?
  • Investigations with general non-postpartum
    immigrant populations have clearly demonstrated a
    link between the acculturation process and
    psychological problems

  • 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)

  • 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

  • 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

  • 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

  • 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)

  • 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

  • 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

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

  • Traditional postpartum rituals among
    indigenous/native mothers (including rationale
    for practices)
  • organized support (includes who, where, what
    activities, etc.)
  • dietary practices
  • restricted physical activities
  • hygiene practices
  • celebrations (e.g., naming baby)
  • other rituals

  • 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

  • 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)

  • 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,

  • 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

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.

  • Cultures which use technology to monitor new
  • 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

  • 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

  • Postpartum support structures
  • Mandated rest and assistance with household tasks
  • Maternal vulnerability
  • Social seclusion
  • Recognition of role transition

Cultural PPD Risk Factors
  • Acculturative stress
  • Traditional postpartum practices

Why does postpartum depression often remain
  • The lack of detection is not just a health
    professional issue that can be dealt with by just
  • 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.

Maternal Barriers
  • Reluctant to obtain professional assistance
  • Unwilling to disclose emotional problems
    especially depression
  • Popular myth equates motherhood with happiness

  • 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

  • Lack knowledge about PPD
  • Not aware they are suffering from the condition
  • Deny and minimize symptoms
  • Difficulty understanding the problems they are
  • assume struggles are normal for mothers
  • reasonable response to adversity

  • Conversely, some women recognize depression but
  • having child taken aware
  • being labelled mentally ill
  • not fulfilling role as mother
  • obtaining a more serious mental diagnosis

  • Also, depression implies weakness or perceived
  • Family members may discourage help seeking in
    some cultures it is unacceptable to admit to
    depressive symptoms
  • Some family member lack knowledge about PPD

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

  • Normalize symptoms and dismiss as self-limiting
  • Mothers obtaining professional assistance felt
    disappointment, frustration, humiliation, and
  • Patronizing attitudes increased feelings of
    worthlessness and guilt in inability to cope

  • Insufficient time in consultations
  • Prefer to prescribe medication that alleviated
    symptoms but reinforced feelings of inadequacy
  • Not referred to secondary services
  • Language barriers

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

  • 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

  • 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

Clinical Implications Strategies For Caring
For Mothers From Different Cultures
  • Education about PPD is important for women as it
    could enable earlier recognition and help-seeking
  • Information about services and health
    professionals 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

  • 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
  • This may involve the use of symptom and
    context-based terms such as tension, weakness,
    and difficulties in ones relationship at home

  • 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 womans cultural
    group could mean devaluing the mother as a person

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

  • Opportunity to Talk about Feelings
  • Women want
  • to be given permission to talk in-depth about
    their feelings, including ambivalent and
    difficult feelings
  • 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
  • recognition that there is a problem and
    reassurance that other mothers experience similar
    feelings and that they will get better

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

  • 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)

  • 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

Meaning of Care
US Mothers
  • 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)

  1. Having sufficient knowledge about postpartum
  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

Jordanian Mothers
  • 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)

  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

  • 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

Improve detection and treatment of PPD
  • Be aware of acculturative stress
  • Acknowledge traditional postpartum rituals
  • Address barriers to seeking help
  • Provide culturally sensitive treatment based on
    maternal perceptions

What is 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

  • Screening tools do not diagnose a condition
  • Only identifies individuals who are
  • at risk of developing the condition
  • are displaying potential symptoms of the
  • In the case of PPD, health professionals could
    use screening procedures to identify women with
    depressive symptoms who may require additional

  • 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
  • false negative
  • individuals wrongly reported as not having the

What tools can health professionals use to
detect postpartum depression?
  • 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

  • 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

  • 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

Accurate Assessment and Detection
  • 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

  • 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

  • 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
  • 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

  • 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

  • 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
  • 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
  • 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

  • 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
  • PPD prevalence rates
  • Patterns of inception
  • EPDS accuracy

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

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)

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?
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
  • to recommend the use of screening tools in
  • routine antenatal care

  • 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

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

  • 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

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
  • Strong research evidence suggests that low
    maternal mood in the immediate postpartum period
    is highly predictive of the development of PPD

  • A significant proportion of the women who screen
    positive for depression at 1 to 2 weeks
    postpartum may not meet diagnostic criteria for
  • Women who do not actually require treatment for
    PPD might consume substantial resources

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
  • Research has not determined exactly how much
    later to administer the screening tool again

RNAO Best Practice Guideline
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

Purpose and Scope
  • Confirmation, prevention and treatment of mothers
    with depressive symptoms in the first postpartum

Recommendations for Detecting Depressive Symptoms
(application to mothers from different cultures)
  • EPDS is the recommended self-report tool to
    confirm depressive symptoms in postpartum
  • The EPDS can be administered anytime throughout
    the postpartum period (birth to 12 months) to
    confirm depressive symptoms

  • Encourage mothers to complete the EPDS by
    themselves in privacy

  • 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

  • The EPDS must be interpreted in combination with
    clinical judgment to confirm mothers with
    depressive symptoms

  • 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

Many unanswered questions remain
New Mothers in a New Country Understanding
Postpartum Depression among Recent Immigrant and
Canadian-Born Chinese Women Principal
Investigator Dr. C-L 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

  • To determine patterns of PPD help-seeking
    behaviours and barriers to health services among
    recent immigrant Chinese mothers

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
  • 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

  • Participating mothers will complete baseline
    information within 4 weeks postpartum
  • All mothers will be followedup at 12, 24 and 52
    weeks postpartum via telephone by trained
    research assistants

  • The study results will make substantive
    contributions in seven areas
  • Provide information about PPD prevalence and
    inception rates among recently immigrated and
    Canadian-born Chinese women
  • 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
  • Advance our understanding of the relationship
    between recent immigrant status, the
    acculturation process, and PPD

  1. Determine which traditional postpartum rituals
    are maintained post-migration and the effect of
    these practices on the development of PPD
  2. Investigate health service utilization barriers
    and help-seeking behaviours related to PPD
  3. Promote cultural sensitivity among health
  4. Guide the development of a randomized controlled
    trial to evaluate a culturally-sensitive PPD

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
  • Peel - Windsor
  • Halton - Ottawa
  • York - Sudbury
  • Toronto

Relevance for Screening
  • PPD prevalence rates for a multicultural
  • Accuracy of screening for PPD at 1 week
  • 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