Hostname: page-component-5d84bcc8dc-5t224 Total loading time: 0 Render date: 2026-09-13T17:11:50.336Z Has data issue: false hasContentIssue false
  • English
  • Français

The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale

Published online by Cambridge University Press:  21 November 2016

A. Di Florio ,
K. Putnam ,
M. Altemus ,
G. Apter ,
V. Bergink ,
J. Bilszta ,
R. Brock ,
A. Buist ,
K. M. Deligiannidis  and
E. Devouche
...Show all authors
A. Di Florio
Affiliation:
Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, UK
K. Putnam
Affiliation:
Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
M. Altemus
Affiliation:
Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
G. Apter
Affiliation:
Erasme Hospital, Paris Diderot University, Paris, France
V. Bergink
Affiliation:
Department of Psychiatry/Psychology, Erasmus MC, Rotterdam, The Netherlands Department of Economics and Business, National Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
J. Bilszta
Affiliation:
Women's Mental Health, University of Melbourne, Melbourne, VIC, Australia
R. Brock
Affiliation:
Department of Psychological and Brain Sciences, The University of Iowa, Iowa City, IA, USA
A. Buist
Affiliation:
Women's Mental Health, University of Melbourne, Melbourne, VIC, Australia
K. M. Deligiannidis
Affiliation:
Departments of Psychiatry and Obstetrics and Gynecology, Hofstra Northwell School of Medicine, Glen Oaks, NY, USA
E. Devouche
Affiliation:
Erasme Hospital, Paris Descartes University, Paris, France
C. N. Epperson
Affiliation:
Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
C. Guille
Affiliation:
Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
D. Kim
Affiliation:
Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
P. Lichtenstein
Affiliation:
Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
P. K. E. Magnusson
Affiliation:
Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
P. Martinez
Affiliation:
Behavioral Endocrinology Branch, National Institute of Mental Health, National Institutes of Health, Health and Human Services, Bethesda, MD, USA
T. Munk-Olsen
Affiliation:
Department of Economics and Business, National Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
J. Newport
Affiliation:
Department of Psychiatry, University of Miami, Miami, FL, USA
J. Payne
Affiliation:
Department of Psychiatry, The Johns Hopkins University, Baltimore, MD, USA
B. W. Penninx
Affiliation:
Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
M. O'Hara
Affiliation:
Department of Psychological and Brain Sciences, The University of Iowa, Iowa City, IA, USA
E. Robertson-Blackmore
Affiliation:
Department of Family Medicine, Halifax Health, Daytona Beach, FL, USA
S. J. Roza
Affiliation:
Department of Psychiatry/Psychology, Erasmus MC, Rotterdam, The Netherlands
K. M. Sharkey
Affiliation:
Department of Psychiatry, Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
S. Stuart
Affiliation:
Department of Psychological and Brain Sciences, The University of Iowa, Iowa City, IA, USA
H. Tiemeier
Affiliation:
Department of Psychiatry/Psychology, Erasmus MC, Rotterdam, The Netherlands
A. Viktorin
Affiliation:
Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
P. J. Schmidt
Affiliation:
Behavioral Endocrinology Branch, National Institute of Mental Health, National Institutes of Health, Health and Human Services, Bethesda, MD, USA
P. F. Sullivan
Affiliation:
Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Z. N. Stowe
Affiliation:
Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
K. L. Wisner
Affiliation:
Asher Center for the Study and Treatment of Depressive Disorders, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
I. Jones
Affiliation:
Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, UK
D. R. Rubinow
Affiliation:
Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
S. Meltzer-Brody*
Affiliation:
Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
*
*Address for correspondence: S. Meltzer-Brody, Department of Psychiatry, University of North Carolina at Chapel Hill, Campus Box #7160, Chapel Hill, NC 27599, USA. (Email: meltzerb@med.unc.edu)
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.

Method

Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.

Results

Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) < 0.01]. The structure of EPDS responses significantly differed between Europe and the USA (∆*CFI > 0.01), but not between European countries (∆*CFI < 0.01).

Conclusions

Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.

Keywords

CultureEdinburgh Postnatal Depression Scale (EPDS)educationpostpartum depressionrace

Information

Type
Original Articles
Information
Psychological Medicine , Volume 47 , Issue 5 , April 2017 , pp. 787 - 799
Copyright
Copyright © Cambridge University Press 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Alarcón, RD (2009). Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry 8, 131–139.CrossRefGoogle ScholarPubMed
Alonso, J, Buron, A, Bruffaerts, R, He, Y, Posada-Villa, J, Lepine, J-P, Angermeyer, MC, Levinson, D, de Girolamo, G, Tachimori, H, Mneimneh, ZN, Medina-Mora, ME, Ormel, J, Scott, KM, Gureje, O, Haro, JM, Gluzman, S, Lee, S, Vilagut, G, Kessler, RC, Von Korff, M; World Mental Health Consortium (2008). Association of perceived stigma and mood and anxiety disorders: results from the World Mental Health Surveys. Acta Psychiatrica Scandinavica 118, 305–314.Google Scholar
Bauer, A, Parsonage, M, Knapp, M, Iemmi, V, Adelaja, B (2014). Costs of Perinatal Mental Health Problems. London School of Economics and the Centre for Mental Health: London.Google Scholar
Boots Family Trust (2013). Boots Family Trust Perinatal Mental Health Report (http://www.bftalliance.co.uk/the-report/).Google Scholar
Brown, TA (2015). Confirmatory Factor Analysis for Applied Research, 2nd edn. The Guilford Press: New York and London.Google Scholar
Cantwell, R, Clutton-Brock, T, Cooper, G, Dawson, A, Drife, J, Garrod, D, Harper, A, Hulbert, D, Lucas, S, McClure, J, Millward-Sadler, H, Neilson, J, Nelson-Piercy, C, Norman, J, O'Herlihy, C, Oates, M, Shakespeare, J, de Swiet, M, Williamson, C, Beale, V, Knight, M, Lennox, C, Miller, A, Parmar, D, Rogers, J, Springett, A (2011). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG: An International Journal of Obstetrics and Gynaecology 118 (Suppl. 1), 1–203.Google Scholar
Chatterji, P, Markowitz, S (2012). Family leave after childbirth and the mental health of new mothers. Journal of Mental Health Policy and Economics 15, 61–76.Google ScholarPubMed
Chentsova-Dutton, YE, Ryder, AG, Tsai, J (2014). Understanding depression across cultural contexts. In Handbook of Depression, 3rd edn. (ed. Gotlib, IH and Hammen, CL), pp. 337–354. Guilford: New York.Google Scholar
Comstock, GW, Helsing, KJ (1976). Symptoms of depression in two communities. Psychological Medicine 6, 551–563.Google Scholar
Cook, TM, Wang, J (2010). Descriptive epidemiology of stigma against depression in a general population sample in Alberta. BMC Psychiatry 10, 29.Google Scholar
Cooper, WO, Willy, ME, Pont, SJ, Ray, WA (2007). Increasing use of antidepressants in pregnancy. American Journal of Obstetrics and Gynecology 196, 544.e1–544.e5.CrossRefGoogle ScholarPubMed
Cox, J, Holden, J, Henshaw, C (2014). Perinatal Mental Health: The Edinburgh Postnatal Depression Scale (EPDS) Manual, 2nd revised edn. RCPsych Publications: London.Google Scholar
Cox, JL (1988). Childbirth as a life event: sociocultural aspects of postnatal depression. Acta Psychiatrica Scandinavica. Supplementum 344, 75–83.CrossRefGoogle ScholarPubMed
Cox, JL, Holden, JM, Sagovsky, R (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry: The Journal of Mental Science 150, 782–786.Google Scholar
Cunningham, NK, Brown, PM, Page, AC (2014). Does the Edinburgh Postnatal Depression Scale measure the same constructs across time? Archives of Women's Mental Health 18, 793–804.CrossRefGoogle ScholarPubMed
Dagher, RK, McGovern, PM, Dowd, BE (2014). Maternity leave duration and postpartum mental and physical health: implications for leave policies. Journal of Health Politics, Policy and Law 39, 369–416.Google Scholar
Dagher, RK, McGovern, PM, Dowd, BE, Lundberg, U (2011). Postpartum depressive symptoms and the combined load of paid and unpaid work: a longitudinal analysis. International Archives of Occupational and Environmental Health 84, 735–743.Google Scholar
Dolbier, CL, Rush, TE, Sahadeo, LS, Shaffer, ML, Thorp, J; Community Child Health Network Investigators (2013). Relationships of race and socioeconomic status to postpartum depressive symptoms in rural African American and non-Hispanic white women. Maternal and Child Health Journal 17, 1277–1287.CrossRefGoogle ScholarPubMed
Eberhard-Gran, M, Eskild, A, Tambs, K, Opjordsmoen, S, Ove Samuelsen, S (2001). Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta Psychiatrica Scandinavica 104, 243–249.Google Scholar
Edge, D, Rogers, A (2005). Dealing with it: black Caribbean women's response to adversity and psychological distress associated with pregnancy, childbirth, and early motherhood. Social Science and Medicine (1982) 61, 15–25.CrossRefGoogle ScholarPubMed
Gan, Z, Li, Y, Xie, D, Shao, C, Yang, F, Shen, Y, Zhang, N, Zhang, G, Tian, T, Yin, A, Chen, C, Liu, J, Tang, C, Zhang, Z, Liu, J, Sang, W, Wang, X, Liu, T, Wei, Q, Xu, Y, Sun, L, Wang, S, Li, C, Hu, C, Cui, Y, Liu, Y, Li, Y, Zhao, X, Zhang, L, Sun, L, Chen, Y, Zhang, Y, Ning, Y, Shi, S, Chen, Y, Kendler, KS, Flint, J, Zhang, J (2012). The impact of educational status on the clinical features of major depressive disorder among Chinese women. Journal of Affective Disorders 136, 988–992.Google Scholar
Gibson, J, McKenzie-McHarg, K, Shakespeare, J, Price, J, Gray, R (2009). A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatrica Scandinavica 119, 350–364.Google Scholar
Gregorich, SE (2006). Do self-report instruments allow meaningful comparisons across diverse population groups? Testing measurement invariance using the confirmatory factor analysis framework. Medical Care 44, S78–S94.Google Scholar
Guedeney, N, Fermanian, J (1998). Validation study of the French version of the Edinburgh Postnatal Depression Scale (EPDS): new results about use and psychometric properties. European Psychiatry: The Journal of the Association of European Psychiatrists 13, 83–89.Google Scholar
Hirschfeld, G, von Brachel, R (2014). Multiple-group confirmatory factor analysis in R – a tutorial in measurement invariance with continuous and ordinal indicators. Practical Assessment, Research & Evaluation 19, 1–12 (http://pareonline.net/getvn.asp?v=19&n=7).Google Scholar
Keller, MC, Neale, MC, Kendler, KS (2007). Association of different adverse life events with distinct patterns of depressive symptoms. American Journal of Psychiatry 164, 1521–1529; quiz 1622.Google Scholar
Kendler, KS, Aggen, SH, Li, Y, Lewis, CM, Breen, G, Boomsma, DI, Bot, M, Penninx, BWJH, Flint, J (2015). The similarity of the structure of DSM-IV criteria for major depression in depressed women from China, the United States and Europe. Psychological Medicine 45, 1945–1954.Google Scholar
Kozhimannil, KB, Kim, H (2014). Maternal mental illness. Science 345, 755–755.CrossRefGoogle ScholarPubMed
Kroeber, AL, Kluckhohn, C (1952). Culture: a critical review of concepts and definitions. Papers of the Peabody Museum of American Archeology and Ethnology 47, 223.Google Scholar
Kumar, R (1994). Postnatal mental illness: a transcultural perspective. Social Psychiatry and Psychiatric Epidemiology 29, 250–264.CrossRefGoogle ScholarPubMed
Lara-Cinisomo, S, Wisner, KL, Meltzer-Brody, S (2015). Advances in science and biomedical research on postpartum depression do not include meaningful numbers of Latinas. Journal of Immigrant and Minority Health/Center for Minority Public Health 17, 1593–1596.CrossRefGoogle Scholar
Meltzer-Brody, S (2011). New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues in Clinical Neuroscience 13, 89–100.Google Scholar
Meltzer-Brody, S, Boschloo, L, Jones, I, Sullivan, PF, Penninx, BW (2013). The EPDS-Lifetime: assessment of lifetime prevalence and risk factors for perinatal depression in a large cohort of depressed women. Archives of Women's Mental Health 16, 465–473.Google Scholar
Millsap, RE (2011). Statistical Approaches to Measurement Invariance. Routledge: New York.Google Scholar
Munk-Olsen, T, Gasse, C, Laursen, TM (2012). Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women. Acta Psychiatrica Scandinavica 125, 318–324.CrossRefGoogle ScholarPubMed
Munk-Olsen, T, Laursen, TM, Pedersen, CB, Mors, O, Mortensen, PB (2006). New parents and mental disorders. JAMA 296, 2582–2589.Google Scholar
O'Connor, E, Rossom, RC, Henninger, M, Groom, HC, Burda, BU (2016). Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA 315, 388–406.CrossRefGoogle ScholarPubMed
Paykel, ES (2008). Basic concepts of depression. Dialogues in Clinical Neuroscience 10, 279–289.Google Scholar
Pop, VJ, Komproe, IH, van Son, MJ (1992). Characteristics of the Edinburgh Post Natal Depression Scale in the Netherlands. Journal of Affective Disorders 26, 105–110.CrossRefGoogle ScholarPubMed
Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium (2015). Heterogeneity of postpartum depression: a latent class analysis. Lancet Psychiatry 2, 59–67.CrossRefGoogle Scholar
Ray, R, Gornick, JC, Schmitt, J (2010). Who cares? Assessing generosity and gender equality in parental leave policy designs in 21 countries. Journal of European Social Policy 20, 196–216.Google Scholar
Schomerus, G, Matschinger, H, Baumeister, SE, Mojtabai, R, Angermeyer, MC (2014). Public attitudes towards psychiatric medication: a comparison between United States and Germany. World Psychiatry 13, 320–321.Google Scholar
Shonkoff, JP, Boyce, W, McEwen, BS (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA 301, 2252–2259.Google Scholar
Teng, L, Robertson Blackmore, E, Stewart, DE (2007). Healthcare worker's perceptions of barriers to care by immigrant women with postpartum depression: an exploratory qualitative study. Archives of Women's Mental Health 10, 93–101.Google Scholar
Tolstoy, L (1878 [1939]). Anna Karenina. Oxford University Press/Humphrey Milford: Oxford.Google Scholar
Venables, WN, Ripley, BD (2003). Modern Applied Statistics with S, 4th edn. Springer: New York.Google Scholar
Wisner, KL, Sit, DKY, McShea, MC, Rizzo, DM, Zoretich, RA, Hughes, CL, Eng, HF, Luther, JF, Wisniewski, SR, Costantino, ML, Confer, AL, Moses-Kolko, EL, Famy, CS, Hanusa, BH (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry 70, 490–498.Google Scholar