Transcript Importance of Graduate Education

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
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
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
Risk Factors (Beck, 2001)
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Dr.Cindy-Lee Dennis
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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
Dr.Cindy-Lee Dennis
Postdoctoral Research Fellowship
Dr.Cindy-Lee Dennis

UBC, Faculty of Medicine, Dept. Health Care &
Epidemiology

Population-based study - 645 mothers completed
questionnaires at 1, 4, and 8 weeks postpartum
Edinburgh Postnatal Depression
Scale (EPDS)
Dr.Cindy-Lee Dennis
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10-item self-report instrument

Designed specifically to assess depressive
symptoms in new mothers
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Cut-off >12 = confirm postpartum depression
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Cut-off > 9 = community-based screening
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Translated into diverse languages
Sample Characteristics
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Dr.Cindy-Lee Dennis 
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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
Question
Who is at risk for depressive symptoms in
the immediate postpartum period?
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Dr.Cindy-Lee Dennis 
A multifactorial predictive model was developed
using sequential logistic regression analysis
The outcome was an EPDS score > 9 at 1-week
postpartum
Socio-Demographic Factors
1.
2.
3.
4.
5.
6.
7.
Dr.Cindy-Lee Dennis
8.
9.
Marital status
Age
Education
Ethnicity
Immigration during the last five years
Household income
Ability to manage with income
Access to transportation
Suitable housing
Biological/Psychological Factors
Dr.Cindy-Lee Dennis
1.
Vulnerable personality
2.
Self-Esteem
3.
Premenstrual symptoms
4.
Maternal psychiatric history
5.
Family psychiatric history
6.
History of postpartum depression
Pregnancy Factors
Dr.Cindy-Lee Dennis
1.
Infertility problems
2.
Planned pregnancy
3.
Mother’s feelings about pregnancy
4.
Partner’s feelings about pregnancy
5.
Pregnancy complications
Life Stressors
Dr.Cindy-Lee Dennis
1.
Life events (past 12 months)
2.
Job stress
3.
Worrying about returning to work
4.
Satisfaction with job
Substance Abuse and Violence
1.
2.
3.
4.
5.
Dr.Cindy-Lee Dennis
6.
Use of alcohol and drugs by the mother or her
partner
History of physical or sexual abuse
Fear of partner
History of physical abuse as a child
Physical abuse directed towards the subject’s
mother by her father
Interaction with child protection services
Social Support
Dr.Cindy-Lee Dennis
1.
Global Support
2.
Relationship-Specific Support from:
–
Partner
–
Mother
–
Mother-in-law
–
Other women with children
Obstetrical Factors
Dr.Cindy-Lee Dennis
1.
Induction of labour
2.
Mode of delivery
3.
Satisfied with pain management
4.
Control during labour
5.
Labour complications
Maternal Adjustment
Dr.Cindy-Lee Dennis
1.
Ready for hospital discharge
2.
Infant feeding method
3.
Satisfaction with infant feeding method
Dr.Cindy-Lee Dennis
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In the multivariate analysis, significant variables
were tested and retained in the model if the pvalue for the beta-estimate was 0.05 or less
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Variables were entered into the model in the
following chronological order: sociodemographic, biological/psychological,
pregnancy, life stressors, substance
abuse/violence, social support, obstetric, and
maternal adjustment.
Risk Factor
Dr.Cindy-Lee Dennis
Beta
OR
95% CI
Immigrated within last five
years
History of depression before
pregnancy
Vulnerable personality
1.60
4.94
1.00-24.8
0.60
1.82
1.05-3.16
0.20
1.21
1.13-1.31
Life stressors
0.12
1.12
1.01-1.24
Pregnancy-induced
hypertension
Global support
1.28
3.62
1.05-9.74
-.04
0.96
0.93-0.99
Satisfaction with infant feeding
method
Ready for hospital discharged
.83
2.29
1.13-4.64
1.33
3.78
1.40-10.19
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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
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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
Dr.Cindy-Lee Dennis
Why are immigrant women at
risk for PPD?
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Dr.Cindy-Lee Dennis
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)
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
Dr.Cindy-Lee Dennis
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Research also suggests factors may have a
protective effect on acculturative stress,
including the provision of social support and
socio-economic status
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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)
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
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Dr.Cindy-Lee Dennis
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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):
1.
2.
3.
4.
Dr.Cindy-Lee Dennis
5.
6.
organized support (includes who, where, what
activities, etc.)
dietary practices
restricted physical activities
hygiene practices
celebrations (e.g., naming baby)
other rituals
Example

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
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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
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Additionally, someone (usually a female family
member) assumes most of the infant care and
household responsibilities
Dr.Cindy-Lee Dennis
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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)
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Dr.Cindy-Lee Dennis
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
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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 inlaws (Matthey, Panasetis, & Barnett, 2002)
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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
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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
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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
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Dr.Cindy-Lee Dennis
Posmontier, B., & Horowitz, J. A. (2004).
Postpartum practices and depression
prevalences: technocentric and ethnokinship
cultural perspectives. Journal of Transcultural
Nursing, 15(1), 34-43.
Technocentric
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Dr.Cindy-Lee Dennis
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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
Ethnokinship
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Dr.Cindy-Lee Dennis
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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
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Dr.Cindy-Lee Dennis
Postpartum support structures
Mandated rest and assistance with household
tasks
Maternal vulnerability
Social seclusion
Recognition of role transition
Cultural PPD Risk Factors
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Dr.Cindy-Lee Dennis
Acculturative stress
Traditional postpartum practices
Why does postpartum depression
often remain undetected?
Dr.Cindy-Lee Dennis
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The lack of detection is not just a health
professional issue that can be dealt with by just
screening
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Women do not proactively seek help
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Dennis, C-L., & Chung-Lee, L. (submitted). A review of
postpartum depression help-seeking behaviours and
treatment preferences. Birth.
Maternal Barriers
Dr.Cindy-Lee Dennis
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Reluctant to obtain professional assistance
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Unwilling to disclose emotional problems
especially depression
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Popular myth equates motherhood with
happiness
Dr.Cindy-Lee Dennis
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Do not know where to obtain assistance
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Unaware of treatment options
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Perceive health professional role to address
physical symptoms not emotional problems
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Somatization - women translate emotional
distress into physical symptoms
Dr.Cindy-Lee Dennis
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Lack knowledge about PPD
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Not aware they are suffering from the condition
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Deny and minimize symptoms
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Difficulty understanding the problems they are
experiencing
– assume struggles are normal for mothers
– reasonable response to adversity
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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
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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
Health Professional Barriers
Dr.Cindy-Lee Dennis
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Limited training in the assessment and
management of PPD
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Feel uncertain about how to effectively assist
therefore reluctant to raise such issues
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Normalize symptoms and dismiss as selflimiting
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Mothers obtaining professional assistance felt
disappointment, frustration, humiliation, and
anger
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Dr.Cindy-Lee Dennis
Patronizing attitudes – increased feelings of
worthlessness and guilt in inability to cope
Dr.Cindy-Lee Dennis
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Insufficient time in consultations
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Prefer to prescribe medication that alleviated
symptoms but reinforced feelings of inadequacy
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Not referred to secondary services
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Language barriers
Health Service Utilization
Dr.Cindy-Lee Dennis
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Culture constitutes an important context for
affective conditions as shared beliefs, attitudes,
and norms for emotional responses influences
how mothers experience depression
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Culture also determines help-seeking behaviours
and health service utilization
Dr.Cindy-Lee Dennis
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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
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
Dr.Cindy-Lee Dennis
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Education about PPD is important for women as
it could enable earlier recognition and helpseeking

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
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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
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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
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Health professionals should also be aware of
traditional postpartum practices and understand
the rationale behind such practices
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Meaning of traditional practices to the mother
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Preliminary research suggests that devaluing
traditional practices based on a woman’s cultural
group could mean devaluing the mother as a
person
Treatment Preferences
Pharmacological Interventions
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Dr.Cindy-Lee Dennis 
Women are often reluctant to take antidepressant
medication even after receiving education
Fear of addiction
Potential side-effects or harm related to longterm use
Concerns influenced medication compliance
Opportunity to Talk about Feelings
Women 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
Dr.Cindy-Lee Dennis
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The ways in which individual women
interpreted, negotiated, and experienced social
norms of motherhood depends in part on their
interpersonal relationships with other mothers
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Support from other women with children was
perceived as particularly important for recovery
Among immigrant and ethnic minority women:
Dr.Cindy-Lee Dennis
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Support groups facilitated activities such as
shopping and learning English
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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
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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
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Similar results with immigrant mothers living in
the UK (Templeton , 2003)
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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
Dr.Cindy-Lee Dennis
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)
Dr.Cindy-Lee Dennis
1.
2.
3.
4.
5.
6.
Dr.Cindy-Lee Dennis
7.
Having sufficient knowledge about postpartum
depression
Using astute observation and intuition to make
quick, correct diagnoses
Providing hope that the mothers' depression
will come to an end
Readily sharing their time
Making appropriate referrals for the right path
to recovery
Providing continuity of care
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)
Dr.Cindy-Lee Dennis
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
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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
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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
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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
What is Screening?
Screening
Dr.Cindy-Lee Dennis

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
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Screening tools do not diagnose a condition
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Only identifies individuals who are:
– at risk of developing the condition
– are displaying potential symptoms of the
condition
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In the case of PPD, health professionals could
use screening procedures to identify women with
depressive symptoms who may require
additional intervention

Screening has the potential to improve the
quality of life through early diagnosis of a
serious condition
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Screening is not perfect
– false positive
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–
false negative
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Dr.Cindy-Lee Dennis
individuals wrongly reported to have the condition
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., DSMIV]

Measures used to assess for depressive
symptoms include standardized interviews and
self-report questionnaires
Self-Report
Dr.Cindy-Lee Dennis
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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
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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
Dr.Cindy-Lee Dennis

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
Dr.Cindy-Lee Dennis
 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
Dr.Cindy-Lee Dennis
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Unresolved problems related to appropriate cutoff 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
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Okano et al. reported that a cut-off of 8/9 was suitable for
screening Japanese mothers
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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

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
Patterns of inception
EPDS accuracy
2.
3.
Dr.Cindy-Lee Dennis
A Few Points to Consider When Using
the EPDS

Dr.Cindy-Lee Dennis
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.”
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Dr.Cindy-Lee Dennis
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
Dr.Cindy-Lee Dennis 
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
Dr.Cindy-Lee Dennis

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

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
Dr.Cindy-Lee Dennis 
So long as the goal is to detect current rather
than future depression, the EPDS can be useful
during the antenatal period
Postnatal Screening
Dr.Cindy-Lee Dennis

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
Immediate Postpartum Period
Dr.Cindy-Lee Dennis

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
Disadvantage
Dr.Cindy-Lee Dennis

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
Two-Stage Screening
Dr.Cindy-Lee Dennis

Where resources permit, a two-stage screening
process, in which mothers who score positive
during the first screening assessment are readminister 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
Development Panel Members
Cindy-Lee Dennis (Team Leader)
Stephanie Lappan-Gracon (Program Coordinator)
Dr.Cindy-Lee Dennis
Sue Bookey-Bassett
Barbara Bowles
Marilyn Evans
JoAnne Hunter
Karen McQueen
Lori Ross
Sharon Thompson
Bonnie Wooten
Donna Bottomley
Judi De Boeck
Denise Hebert
Elizabeth McGoarty
Phyllis Montgomery
Marcia Starkman
Ulla Wise
Purpose and Scope

Dr.Cindy-Lee Dennis
Confirmation, prevention and treatment of
mothers with depressive symptoms in the
first postpartum year
Recommendations for
Detecting Depressive Symptoms
(application to mothers from different
cultures)
Dr.Cindy-Lee Dennis
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
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
Dr.Cindy-Lee Dennis
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
3.
Dr.Cindy-Lee Dennis
To determine patterns of PPD help-seeking
behaviours and barriers to health services
among recent immigrant Chinese mothers
Study Design
Dr.Cindy-Lee Dennis

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
The study results will make substantive contributions in
seven areas:
Dr.Cindy-Lee Dennis
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
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
–
–
Dr.Cindy-Lee Dennis
–
–
Peel
Halton
York
Toronto
- Windsor
- Ottawa
- Sudbury
Relevance for Screening






Dr.Cindy-Lee Dennis

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