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thesis entitled

POSTPARTUM DEPRESSION SCREENING WITH THE
EDINBURGH POSTNATAL DEPRESSION SCALE AND
THE POSTPARTUM DEPRESSION CHECKLIST

presented by

Mary Pat Mullin

has been accepted towards fulfillment
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POSTPARTUM DEPRESSION SCREENING
WITH THE EDINBURGH POSTNATAL DEPRESSION SCALE
AND THE POSTPARTUM DEPRESSION CHECKLIST

By

Mary Pat Mullin

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

Department of Nursing

1 996

ABSTRACT
POSTPARTUM DEPRESSION SCREENING
WITH THE EDINBURGH POSTNATAL DEPRESSION SCALE
AND THE POSTPARTUM DEPRESSION CHECKLIST
By

Mary Pat Mullin

Postpartum depression is highly prevalent and often undiagnosed. This study
sought to determine the relationship between the Edinburgh Postnatal Depression Scale
(EPDS) and the Postpartum Depression Checklist (PDC), and the sociodemographic
characteristics associated with elevated depression scores. The sample consisted of 30
women returning to an obstetric clinic six to eight weeks postpartum. Statistical analysis
of the data revealed that the EPDS and the PDC had a moderately high degree of
correlation (F764, p<.01). The only sociodemographic characteristic of significance was
being non-white, this correlated with higher depression scores (F-I .95, p=.05). Other
identified risk factors examined were age, marital status, partner/significant other support,
level of education, income level, employment status, planned pregnancy, parity,
complications, type of delivery, history of depression, and family history of depression,
none of which demonstrated a significant association with an elevated depression score.
Implications for advanced practice nurses are discussed in terms of screening for

depression in postpartum women.

COPyright by
MARY PAT MULLIN
1996

This thesis is dedicated to my parents, Pat and Marie Mullin, who have lovingly
encouraged and supported me throughout my life, and to my nephew and niece, Neal and

Taylor Hamilton, who have filled many of my days with love and joy.

iv

ACKNOWLEDGEMENTS

Special recognition is given to the following members of my thesis committee for
their professional guidance: LindaBeth Tiedje
Jacqueline Wright
Carla Barnes
To Cheryl Tatano Beck for allowing me to use the Postpartum Depression
Checklist she developed and her supportiveness of my research. Much thanks to the
physicians and staff of the obstetric clinics where I did the study who were always
supportive and helpful. To the postpartum women I interviewed, who without this study
would not of been possible, for being so receptive and open to sharing their feelings with
me. To Providence Hospital for their donation.
Further acknowledgements are given to the following individuals, who never
failed to offer their support and encouragement: Julie Gargan
Sharon King
Margaret Meyers

Karen Peper

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................................... vii
LIST OF FIGURES ......................................................................................................... viii
INTRODUCTION ....................................................... 1
Background ...................................................... 1
Purpose .......................................................... 3
Study Questions ................................................... 3
LITERATURE REVIEW ................................................. 4
Effects on Women ................................................. 4
Effects on Children ................................................ 4
Assessment ....................................................... 5
Other Factors in Depression .......................................... 9
Conceptual Definition ............................................. 12
Theoretical Framework/Model ...................................... 14
Rationale ....................................................... 19
METHODS ........................................................... 20
Introduction ..................................................... 20
Sample ......................................................... 20
Field Procedures .................................................. 21
Data Collection .................................................. 22
Human Rights Protection ........................................... 24
Operational Definitions ............................................ 24
Sociodemographic Variables ........................................ 24
Instrumentation .................................................. 25
ReliabilityNalidity ............................................... 26
Scoring ......................................................... 28
Research Design .................................................. 29
Data Analysis .................................................... 29
RESULTS/FINDINGS .................................................. 30
Introduction ..................................................... 30
Demographic Characteristics ........................................ 30

vi

Research Questions ............................................... 34

Research question 1 ......................................... 34
Research question 2 ......................................... 35
DISCUSSION ......................................................... 43
Introduction ..................................................... 43
Sociodemographic Trends ......................................... 44
Clinical Perspective ............................................... 46
Assumptions ..................................................... 47
Limitations ...................................................... 47
Recommendation for Further Research ................................ 48
Implications for Advanced Practice Nurses ............................. 48
Conclusion ...................................................... 50
APPENDICES
A. Postpartum Depression Checklist Consent ...................................................... 51
B. Letter of Introduction ....................................................................................... 52
C. Physician Permission ....................................................................................... 53
D. Introduction Script ........................................................................................... 57
E. Patient Consent ................................................................................................ 58
F. Sociodemographic Questionnaire .................................................................... 59
G. Edinburgh Postnatal Depression Scale ........................................................... 61
H. Postpartum Depression Checklist with Probes ............................................... 62
I . Postpartum Depression Resources .................................................................. 64
J. Research Approval .......................................................................................... 65
LIST OF REFERENCES ................................................................................................... 66

vii

LIST OF TABLES

1. DemographicVariables ............................................................................................. 31
2. Pregnancy Variables ................................................................................................. 32
3. Depression Measures ................................................................................................ 33
4. Frequency Distribution for Specific Items on the PDC ............................................ 34
5. t-Test for Two Independent Samples - Scores on EPDS by Age of Mother ........... 36
6. Mann-Whitney U Test for Independent Samples by Revised Race of

Respondent .............................................................................................................. 36
7. Mann-Whitney U Test for Independent Samples by Revised Marital Status of

Respondent ............................................................................................................. 37
8. t-Test for Two Independent Samples - Scores on EPDS by Perceived Level of

Support by Spouse or Significant Other .................................................................. 37
9. Kruskal-Wallis One-Way Analysis of Variance - EPDS by by Educational

Level ........................................................................................................................ 38
10. Kruskal-Wallis One-Way Analysis of Variance - EPDS by Family Income

Level ....................................................................................................................... 39
11. Kruskal-Wallis One-Way Analysis of Variance - EPDS by Employment

Status ........................................................................................................................ 40
12. Mann-Whitney Test for Independent Samples - EPDS by Pregnancy

Complications .......................................................................................................... 41
13. t-Test for Two Independent Samples - Scores on EPDS by First Baby .................. 41
14. Mann-Whitney Test for Independent Samples by EPDS scores by Planned

Pregnancy ................................................................................................................ 42

viii

1.

LIST OF FIGURES

A Conceptual Framework for Nursing: Dynamic Interacting Systems (King, 1971,
p.20) ............................................................................................................................ 15

An Adapted Conceptual Framework for Nursing: Dynamic Interacting Systems
(King, 1971, p. 20) ....................................................................................................... 17

An Adapted Diagram of a Theory of Goal Attainment which depicts the
interrelationships between King's (1981) concepts and the study concepts
(p. 157) ......................................................................................................................... 18

ix

INTRODUCTION
W

The postpartum period for many women is a healthy developmental process.
Postpartum for other women may be a period besieged with transitions that challenge
coping resources and subsequent adaptation. Studies conducted between five and eight
weeks postpartum have shown that postpartum depression occurs at a rate of between 8%
to 23% (O'Hara, 1987). However, only a small proportion of these postpartum women are
identified as depressed by health professionals due to lack of screening (Beck, 1995b).

There are at least three separate postpartum affective disorders that are frequently
labeled postpartum depression. These disorders, the postpartum blues, postpartum
depression, and postpartum psychosis, differ markedly from one another with regard to
onset, severity, and length of symptoms, and each requires distinct nursing interventions
for both postpartum women and their families. In this study postpartum depression, not
postpartum blues or psychosis, will be specifically examined. The postpartum blues are
generally self-limiting, while postpartum psychosis is infrequent and may first present as
postpartum depression (Cox, 1989).

According to Holden and Phil (1991), the present knowledge about postpartum
depression suggests that not only is it a serious condition and one of the commonest
postpartum complications, it is also a serious threat to the health and well-being of the
family. Depression after childbirth may have long-term effects on a woman's personal
happiness, her relationship with her partner, her view of herself as mother, her child's

social, emotional, and cognitive development, and the emotional well-being of the family

as a whole.

Early detection of postpartum depression has been hindered by the tendency of
women to under-report their feelings, and by unclear, diagnostic categories delineating
postpartum disorders. Unless florid manic or depressive symptoms are displayed,
postpartum depression many times remains covert and undiagnosed. Because childbirth
is supposed to be joyful, a woman feels confused, embarrassed, and guilty if she doesn't
conform to the happy maternal stereotype. Our society does not often encourage people
to come forward with symptoms of depression, thus it is unlikely that a woman would
approach the issue of postpartum depression with her health care provider due to denial,
Shame or embarrassment alnterman, Posner & Williams, 1990).

Detection has also been hindered by the use of standardized clinical interviews
and self-report questionnaires that are frequently borrowed from studies used to detect
depression in the general population. The diagnostic criteria used to study child-bearing
women are still based on the assumption that their depression is similar to that exhibited
in the general population (Affonso, Lovett, Paul, & Sheptak, 1990). Many depression
measures have been used such as the Beck Depression Inventory (BDI) and Schedule for
Affective Disorders and Schizophrenia (SADS) that are inappropriate for use with
pregnant and childbearing women (O'Hara, Neinaber, & Zekoski, 1984). It can no longer
be assumed that depression symptoms of childbearing women fit the same diagnostic
criteria for depression as in the general population. Existing depression scales may be
misleading at a time when somatic symptoms such as sleep disturbance do not necessarily
indicated depression (Holden & Phil, 1991).

In reviewing the literature, two tools found to best screen for postpartum

3
depression after delivery were the Edinburgh Postnatal Depression Scale (EPDS), (Cox,

Holden, & Sagovsky, 1987), a self-report questionnaire that mothers themselves
complete, and the Postpartum Depression Checklist (PDC), (Beck, 1995b). The PDC is
designed to be administered by a health professional, thereby engaging mothers in a
dialogue.

was:

The early detection and the development of reliable and valid screening tools
specific to postpartum depression that are easy for health professionals to use are needed.
The purpose of this study is to compare the EPDS and the PDC in order to further
develop screening and detection of depression in postpartum women. The EPDS and the
PDC was administered to postpartum women and the data correlated. Also
sociodemographic data was obtained from subjects to establish who may be a higher risk
for postpartum depression.

With the information fi'om this study, nurses will gain more knowledge regarding
the PDC'S and EPDS'S use in practice for screening postpartum depression, and
characteristics associated with depression.

Wm
(1) What is the relationship between the Edinburgh Postnatal Depression Scale (EPDS)
and the Postpartum Depression Checklist (PDC)?
(2) What sociodemographic characteristics are associated with elevated depression

scores?

LITERATURE REVIEW
Wen

Early assessment and identification of postpartum depression can reduce the ill
effects on women and children. A woman with postpartum depression suffers from
withdraw], irritability, and fatigue, which limits and distorts healthy family interaction.
Postpartum depression and its family sequalae also bring further pain and suffering upon
the woman (Martel, 1990). A mother's depression may be so deep that she may attempt
suicide or infanticide (U garriza, 1990). This is the worst scenario if a woman with
postpartum depression is untreated.

W

Research has consistently demonstrated that maternal depression affects infants
with outcomes ranging from delayed cognitive development (Cogill, Caplan, Alexandra,
Robson, & Kumar, 1986) to behavior disturbances (Whiffen & Gotlib, 1989). The effects
of maternal depression also persist in older children. Behavioral problems have been

~

seen in the three-year-old children of postnatally depressed mothers (Wrate, Rooney &
Thomas, 1985), and significant cognitive deficits were observed in four-year-olds whose
mothers had suffered depression during the children's first year (Cogill, Caplan,
Alexandra, Robson & Kumar, 1986).

The correlates of maternal depression identified in older children may have
evolved from the mothers' inability to provide an appropriate environment for the infants'
psychological development (Murray, 1988). When postpartum depression goes

undetected by health professionals, mothers and their families are left untreated.

5
Assessment

There are three types of assessment of patients for depression: first, a full clinical
interview with a psychiatrist, second, a structured clinical interview, and third, observer-
rated scales. The first two methods are both time-consuming and impractical in screening
large numbers of women, the majority of whom are well. Observer-rated scales are more
practical, but they too require some form of training in their application (Harris, Huckle,
Thomas, Johns & Fung, 1989).

Depression may be overdiagnosed if clinicians use self-reported measures solely,
or without carefully interviewing women to separate the symptoms of depression from
symptoms of pregnancy and postpartum (Affonso, Lovett, Paul & Sheptak, 1990). There
has been a tendency in previous studies to use global measures of independent variables
(i.e; stress, social support) rather than to investigate specific factors that contribute to
postpartum depression (Affonso, 1992).

For example, measures of self control related to postpartum depression as
measured by the Beck Depression Scale (BDI), (Beck, Ward, Mendelson, Mock, &
Erbaugh, 1961) was not confirmed when a clinical syndrome diagnosis of depression was
made using Research Diagnostic Criteria (O'Hara, Rehm & Campbell, 1984). This
suggests that studies using the Beck Depression Inventory as the only measure of
depression following childbirth may give misleading results.

Some possible explanations for these apparent limitations of well established
scales when used on childbearing women include their emphasis on the somatic
symptoms of psychiatric disorder which may be caused by normal physiological changes

associated with childbearing, (i.e; sleep and eating disturbances, fatigue, psychomotor

6

retardation) as well as reluctance to use questionnaires which may be regarded as time-
consuming or which appear to lack face validity (Cox, Holden & Sagovsky, 1987).

Cursory assessments or limited self-report information can result in either an
overdiagnosis of depression or failure to identify a negative emotional state requiring
treatment (Affonso, 1990). To be useful as a screening test for depression following
childbirth, a self-report scale must be fully acceptable to women who may not regard
themselves as unwell, or in need of medical help. The depression scale also needs to be
simple to complete, and not require the health care giver to have any specialized
knowledge of psychiatry. It must have satisfactory reliability and validity. The
Edinburgh Postnatal Depression Scale (EPDS) satisfies these requirements (Cox, Holden,
& Sagovsky, 1987).

The EPDS, a 10 item self-report screening tool, was devised from the earlier work
of Snaith (1978) and concentrates on the psychic aspect of depression in the puerperiurn,
containing within it a rating for anhedonia. Anhedonia is the "absence of pleasure from
the performance of acts that would ordinarily be pleasurable" (Spraycar, 1995, p. 90). Its
only rating of a biological nature is for difficulty sleeping , and unhappiness is specified
as the reason for sleep difficulties, eliminating the confusion with sleep deprivation early
postpartum (Harris, Huckle, Thomas, Johns & Fung, 1989).

The EPDS was developed to assist primary care health professionals to detect
mothers suffering fi'om moderate postpartum depression not the postpartum "blues" or
puerperal psychosis (Cox, Holden, & Sagovsky, 1987). The advantages of such a tool are
obvious in that it is a self-report scale and by design can be used by a variety of health

professionals. The scale does not replace full psychiatric assessment, but identifies a

7

population which needs further evaluation. The scale will not detect mothers with
anxiety neurosis, phobias, or personality disorders. The EPDS'S reliability and validity
are well established (Harris, Huckle, Thomas, Johns & Fung, 1989). The EPDS has been
widely used in Europe, but has only recently been used in the midwest United States
(Schaper, Roonely, Kay, & Silva, 1994). The EPDS has been cited as not giving women
the opportunity to describe their symptoms fully (Holden & Phil, 1991), whereas, the
PDC is more interactive and allows women to describe their symptoms in greater detail.

Unlike the EPDS, the PDC is designed to be administered by a health professional
thereby engaging mothers in a verbal dialogue. Before developing the PDC, two
qualitative studies on postpartum depression were conducted. A phenomenological study
(Beck, 1992) and a grounded theory study (Beck, 1993). Use of two theoretical
perspectives, phenomenology and symbolic interactionism, provided a theoretical basis
that enabled a more complete and holistic portrayal of postpartum depression. The
grounded theory study also confirmed the findings of the phenomenological study.

In the second study, using grounded theory, a substantive theory of postpartum
depression was developed (Beck, 1993). Data were obtained through participant
observation in a postpartum depression support group over an 18-month period. In
addition, 12 in-depth, taped interviews were conducted with mothers who had attended
the support group. Using the constant comparative method, loss of control emerged as
the basic social psychological problem in postpartum depression (Beck, 1995b).

The PDC describes 11 symptoms mothers suffering from postpartum depression
reported experiencing. The 11 items are arranged in a checklist beginning with the least

threatening symptoms, such as lack of concentration, and ending with the most

8

threatening symptom of contemplating death. The checklist is not intended to be used to
make a diagnosis of postpartum depression or to replace a full psychiatric assessment. It
can be used to define a population that may need further evaluation.

When the EPDS is compared with the PDC, there are five symptoms that are not
included in the EPDS: 1) loss of control; 2) obsessive thinking; 3) loss of self; 4)
loneliness; and 5) lack of concentration. There are two symptoms in the EPDS that are
not included on the PDC: 1) difficulty sleeping related to unhappiness, and 2) crying
related to unhappiness.

The PDC'S "loss of interests" question is similar to a EPDS question about
looking forward with enjoyment to things (question two). Both questions encompass the
characteristic of anhedonia. The PDC's insecurity questioning is similar to EPDS
questions that include feeling scared, panicky, and overburdened (questions five and six).
The PDC questions about lack of positive emotions and feelings of emptiness, feeling
like a robot, and not feeling joy and love toward infant are related to EPDS questions
regarding laughing, seeing the fimny side of things, and feeling sadness and misery
(question one and eight).

The PDC anxiety attacks question regarding periods of palpations, chest pains,
sweating, and tingling hands would compare to a EPDS question of feeling worried or
anxious (question four). The PDC guilt questioning, guilt related to the infant, thoughts
of harm to the infant, and being a good mother, is similar to a EPDS question regarding
blaming self when things go wrong (question three).

Contemplating death is the last question on the PDC as is the related question on

the EPDS inquiring about thoughts of harming self. Both tools progress from least severe

9

to most severe symptoms. In analysis the PDC questions appear to be more
encompassing, time consuming, and specific, but wordy. The EPDS questions appear to
be more general, direct, understandable, and less time consuming. However, in general
not as much information is potentially generated using the EPDS.

The EPDS is a validated instrument developed specifically to identify women
experiencing postpartum depression. The PDC is a newly developed postpartum
screening tool that has been content validated but not criterion validated. By comparing
screening results from the two instruments the PDC's usefirlness in the detection and
screening of postpartum depression will be further established.

Q I E . D .

A review of the literature indicates that various factors may influence the
incidence of postpartum depression. Schaper, Rooney, Kay, and Silva (1994), using the
EPDS with 287 randomly choosen women six weeks postpartum found marital
instability, lack of medical insurance, and a history of depression were the factors found
to correlate significantly with elevated EPDS scores. In addition women who were
unmarried, divorced, separated, or widowed scored significantly higher on the EPDS.
Other identified risk factors which showed no relationship with depression were type of
delivery (vaginal/ceasarean), breast feeding, high-risk pregnancy, unplanned pregnancy,
and peripartum stress. Furthermore, although the woman's occupation was not associated
with depression, if unemployed 43% were at risk of developing postpartum depression
(Schaper, Rooney, Kay, & Silva, 1994). This study was a retrospective chart review that
was conducted by the investigators to identify high-risk factors present in the patient

population. These risk factors were then correlated with the scores on the EPDS.

10

A heterogeneous sample of 360 women an average of 4.2 weeks after delivery
using the Beck Depression Scale (BDI) and Schedule for Affective Disorders and
Schizophrenia (SADS) found that postpartum depression was unrelated to age (Gotlib,
Whiffen, Mount, Milne & Cordy, 1989).

Watson, Elliot, Rugg, and Brough (1984) interviewed 128 women six weeks
postpartum and found a significant association between postpartum depression and
dissatisfaction with the marital relationship and a previous psychiatric history. The study
showed no association of postpartum depression with social class, martial status, or
parity.

In a study of 99 women assessed at three and six weeks postpartum for depression
the researchers found a Significant association between postpartum depression and a
history of depression and family history of depression (O'Hara, Neunaber & Zekoski,
1984)

Paykel, Emms, Fletcher, and Rassaby (1980), assessed 120 women six weeks
postpartum in a clinic setting for postpartum depression using the Raskin 3- Area
Depression Scale. A previous psychiatric history and marital discord was significantly
associated with depression. While social class, being unmarried, parity, and unplanned
pregnancy showed no association woth postpartum depression.

Postpartum factors associated with depression in the literature are personal or
family history of depression, stressful life events, cognitive style, lack of social or
economic support, hormonal sensitivity, obstetric stress, and genetic variables (Schaper,
Rooney, Kay, & Silva, 1994). Inadequate financial resources and dissatisfaction with

education are also factors associated with postpartum depression (Posner, Unterman, &

1 1
Williams, 1985).

One finding deserves particular attention because of its consistency in many
postpartum studies (Bookman-Livingood, Daen & Smith, 1983; Paykel, Emms, Fletcher
& Rassaby, 1981; O'Hara, Rehm, & Campbell, 1983; Oakley, 1980; Watson, Elliot, Rugg
& Brough, 1984; and Cox, Conner & Kendall, 1982) that have documented a relationship
between postpartum depression and 'marital difficulties' or a 'poor relationship with the
husband.’

Even though different authors use the term 'marital difficulties' to describe
somewhat different phenomena (communication, affection, support), the consistency with
which the role of the husband is associated with postpartum depression is striking
However, some have suggested that it is the woman's mental state which is responsible
for the marital problems in the first place, so depression may be a cause not an effect of
marital difficulties (Romitio, 1989).

A review of the literature revealed that studies involve many different samples of
women, with different instruments and criteria for depression, and at many different times
after birth. It is not surprising that many factors have been proposed as associated with
postpartum depression.

Despite many factors suggesting risk for postpartum depression in the literature
overall it is still difficult to predict. Data was collected on the following
sociodemographic variables in this study: age, marital status, partner/significant other
support, level of education, income level, employment status, planned pregnancy, parity,
complications, type of delivery, history of depression, and family history of depression.

All variables chosen were suggested in the literature as being associated with postpartum

12

depression.
mm

There is an implicit notion that postpartum depression occurs sometime in the first
12 months following childbirth. Even within this time span, there is no clear agreement
on either the onset or duration of the disorder. The greatest incidence varies from
occurring two weeks after childbirth (Lepper, DiMattio, & Tinsley, 1994); four weeks
(McIntosh, 1993); five weeks (Cox, Murray, & Chapman,l993);and six weeks (Holden &
Phil, 1991).

The average duration ranges from at least two weeks, (Ugarriza, 1992); two
months, (Lepper, DiMatteo, & Tinsley, 1994); to thirty-Six weeks (Cox, Murray, &
Chapman, 1993); with others indicating a duration of one year or more (Cox, Holden &
Sagovsky, 1987). Clearly, there is no agreement on the onset and duration of postpartum
depression.

Furthermore, there is no widely accepted definition of postpartum depression.
Wolman, Chalmers, Hofineyr, and Nikodem (1993), describe postpartum depression as
"...a group of poorly defined, depressive type symptoms that have their onset in the early
postpartum weeks or months and can persist for more than a year" (p. 1388). These
symptoms because of their severity or persistence, cause debilitating problems for
postpartum women.

In general postpartum depression can be defined, as "a recurrent and pervasive
state of apathy, despair, disorientation, agitation, or helplessness occurring in a woman

within the first year following the birth of a child" (Landy, Montgomery & Walsh, 1989,

p. 2).

13
According to the American Psychiatry Association criteria (Diagnostic and

Statistical Manual of Mental Disorders, 4th edition, DSM-IV, 1994), moderate
postpartum depression is classified as a major depressive disorder with onset within four
weeks postpartum. These women are characterized as having severe anxiety, panic
attacks, spontaneous crying, disinterest in their infant, insomnia, and guilt.

Clarification must be made between postpartum depression and two other
disorders that may occur after childbearing. These are the mild postpartum "blues" and
severe postpartum psychosis. According to Nicolson (1990), "It is estimated that 50% to
75% of all women who bear a child experience at least some transitory blues" (p. 3).

The postpartum "blues" are the transitory weepiness, irritability, fatigue, mild
confusion, and anxiety which usually last no longer than two or three days, and are
restricted to the first two weeks after childbirth. It is generally accepted that this
particular emotional response is due to the wide hormonal fluctuations that occur during
labor, delivery, and the immediate postpartum period (Gitlin, 1989). It is also important
to recognize that in rare instances what appears to be severe blues can merge into a
postpartum depression when the mother returns home or, more rarely, be the early
symptoms of a major psychoses (Cox, 1989).

Postpartum psychosis is a severe illness that occurs in only one or two per 1,000
deliveries (Kendall, 1984). The clinical features of postpartum psychosis include
delusions, hallucinations, incoherence or loosening of associations, and grossly
disorganized or catatonic behavior. Postpartum psychosis usually surfaces within three
weeks of delivery (Gjerdingen, F roberg, & Wilson, 1986).

The conceptual definition for postpartum depression for purposes of this study

14

includes any of the following pervasive symptoms in the six to eight weeks after
childbirth: loss of control, obsessive thinking, loss of self, loneliness, lack of
concentration, loss of interests, insecurity, lack of positive emotions, anxiety, guilt,
contemplating death, difficulty sleeping, and crying (Beck, 1995b; and Cox, Holden, &
Sagovsky, 1987).

W

The foundation for this study was based on King's (1971, 1981) framework for
nursing (See Figure 1). The conceptual model addresses client interaction and nursing.
King's model focuses on the deliberate action of the client and the achieving of a goal or
result. In this framework, nursing is defined as a "process of human interactions between
nurse and client whereby each perceives the other and the situation, and through
communication, they set goals, explore the means and agree on the means to achieve
goals" (King, 1981, p. 144).

King's conceptual framework is based on a systems approach of viewing human
interaction and nursing. There are three dynamic systems with King's interacting systems
framework: (a) individuals as personal systems; (b) two or more individuals forming
interpersonal systems and; (c) larger groups with common interests and goals forming
social systems. These three open systems consist of individuals or groups of individuals
interacting with one another, influencing one another, and the world around them for a

purpose. For the purpose of this study postpartum depression is conceptualized within

/ SOCIAL SYSTEMS
( (Society)

INTERFERSONAL SYSTEMS

\
I
(Groups)
f- ----- T\ i :
PERSONAL SYSTEMS I
I
I

l
l
I
' (Individuals)
: s P
i A r----:;>
l ' I
I
l l
: I
I

Figure 1. A conceptual framework for nursing: dynamic interacting systems (King, 1971,
p. 20).

16

the personal system and screening within the interpersonal system (see Figure 2 for
adapted framework).

Screening is conceptualized fiom King's (1981) concept of interaction for
interpersonal systems. King placed the concept of interaction within the interpersonal
system because interaction occurs between two people. The nurse and client come
together to help and be helped to maintain a state of health that permits functioning in
roles. King's theory of goal attainment occurs in the interpersonal system with
interaction.

Screening can be conceptualized within this theory. Both nurse and postpartum
woman perceive judge, act, and react, and interact with one another for transaction. The
nurse's role is already set as the screener for the purpose of this study.

King's theory of goal attainment has been adapted to the postpartum mother (see
Figure 3). Perceptions of the woman are postpartum concerns modified by past
experience and present sociodemographic factors. Judgement is her evaluation of the
postpartum period based on perceptions. Actions are the mental and physical behaviors
used to overcome postpartum stressors.

Reactions are the signs and symptoms of postpartum depression experienced by
the woman. Interaction is between the postpartum woman and nurse with screening for
postpartum depression. Transaction is the outcome of postpartum depression screening.
This may be the indication for mental health intervention. If postpartum depression is
found then interaction would transpire with postpartum depression intervention as the

goal the outcome then would be mental health. According to King, interaction is

l7

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Postpartum Care Services
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(Postpartum Depression Scr/eening)/

     
   

 
 
 

 

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//

v’ /
PERSONAL SYS— I EMS
I (Individuals)

Postpartum Woman / / /
/” (Postpartum Depression) .

 

 

 

 

Figure 2. An adapted conceptual framework for nursing: dynamic interacting systems
(King, 1971, p. 20).

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19
essential for growth, change, and personal development to take place.

Rationale

In view of the high incidence and the nature of the illness, it would be helpful to
screen mothers of newborns to identify those suffering from postpartum depression, and
hence refer them for appropriate help and treatment. However, the need exists to develop
more efficient screening assessments for postpartum depression. The benefits of brief
rating scales to screen for and predict postpartum depression, as found with Cox's EPDS,
are well documented (Affonso, Lovett, Paul, & Sheptak, 1990).

Accurate assessments are crucial for early identification and intervention before
progression of depression necessitates hospitalization or lengthy treatments that cause
pain and suffering to the woman and that disrupt interactions in the marriage, with the
infant, and other family members (Affonso, Lovett, Paul & Sheptak, 1990). Undiagnosed
and untreated depression may cause death. Rapid intervention can prevent the tragedies
of suicide, child abuse, and infanticide due to postpartum depression that have been
reported (U garriza, 1990).

Traditional diagnostic depression criteria and assessment methods fail to take into
account the possibility that some depressive symptoms may simply reflect normal

changes and stresses during pregnancy and postpartum.

METHODS
Intrudugtign

This study will describe the relationship between the Postpartum Depression
Checklist (PDC) and the Edinburgh Postnatal Depression Scale (EPDS) and the
sociodemographic characteristics associated with elevated depression scores. The
methodology of the study including sample criteria, field procedures, data collection,
human rights protection, operational definitions, content of the instruments, reliability
and validity of the instruments, scoring and data analysis will be described in this section.

Sample

A convience sample of 30 women were selected, six to eight weeks postpartum,
from three obstetric clinics belonging to the same health-maintenance-organization
within the same suburban community in the midwestem United States. Those who were
minors, below the age of 18, or who could not read and write English were excluded from
the study. Thirty women were asked to participate in the study. The response rate was
100%.

For this study postpartum depression was screened for at six to eight weeks
postpartum, clearly within range according to the onset period of postpartum depression
and adequately removed from the period of postpartum "blues." Holden and Phil (1991),
recommend the EPDS to be given six to eight weeks after childbirth. In previous studies,
diagnostic assessments, have been conducted anywhere from two weeks(Cutrona, 1983)
to 20 weeks postpartum (Cox, Conner, & Kendell, 1982) with the time frame covered by

the interview ranging from one week (Cox, Conner & Kendall, 1982) to nine weeks

20

21
(O'Hara, Neunaber & Zekoski, 1984). In general, the rates of depression obtained later in

the postpartum period are higher than those reported when the interviews are conducted
closer to delivery.

The fact that the cumulative rate of depression continues to increase as women are
assessed later in the postpartum suggests that depression in the postpartum is stable:
women diagnosed as depressed shortly after delivery are likely to continue to be so, as
well as other new women diagnosed depressed later in the postpartum (Gotlib, Whiffen,
Mount, Milne & Cordy, 1989).

EIQIILBLQQEQIILQS

Consent to use the Postpartum Depression Checklist (PDC) and Edinburgh
Postnatal Depression Scale (EPDS) was obtained (see Appendix A). Consent to use the
PDC was obtained from the author . The EPDS may be reproduced without permission
providing copyright is respected by quoting the names of the authors, the title and the
source of the paper in all reproduced copies (Cox, Holden & Sagovsky , 1987).

Personal contact and a letter of introduction was given to the physicians to explain
the purpose of the study (see Appendix B). A copy of the client consent form and
questionnaires accompanied the letter. The researcher personally asked the physicians for
permission to approach their clients for inclusion in the study. Following the physicians'
stated permission to allow their clients to be approached to participate in the study, a
signed letter documentating their agreement was then attained (see Appendix C). Before
contact with the patient was made the researcher obtained the date of the baby's birth
from the receptionist.

A standard script (see Appendix D) was used for each initial contact with the

22

subject in the waiting room. This included the following information: An introduction of
the investigator by name and title, the purpose of the study, and that participation in the
study would require approximately 20 minutes to complete the questionnaires and answer
questions. Women were assured that all information would remain confidential.

If the woman did not wish to participate in the study she was thanked for her time
and communication with her was terminated. If the woman agreed to participate in the
study she was escorted to a clinic room. The researcher then gave the consent form to the
woman, asking her to read it and Sign (see Appendix E). Women were told by the
researcher to feel free to ask any questions. The women were also asked by the .
researcher if they could be referrred to the physician if results indicated a risk for
postpartum depression or if they were likely to be experiencing postpartum depression.

If the participants responded no this was documented on the consent form. No woman
choose to do this.
Winn

After patient consent was obtained each participant received the
sociodemographic questionnaire and EPDS to complete (see Appendix F & G). If
accompanied by another person, participants were requested to complete questionnaires
alone. The researcher asked each participant to answer each question on the
sociodemographic questionnaire to the best of their knowledge and then with the EPDS to
underline the answer that came closest to how they felt that day and within the last week
only. The EPDS also had written instructions with the questionnaire (see Appendix G).
Upon completion of the sociodemographic questionnaire, and the written EPDS, the oral

PDC was administered (see Appendix H).

23

The researcher completed the PDC and gave verbal instructions to the
participants. They were as follows: "I am going to ask you a number of questions on
how you may have felt within the last week. If you have had this feeling answer yes, if
not, no." The researcher then proceeded to ask the items of the PDC. If the participant
answered yes to one of the questions on the PDC then the suggested probing questions
were asked by the researcher. All questions of the PDC were answered with a yes or no.
Some of the questions on the PDC checklist proved difficult for the participants to
understand. When that happened the researcher asked the appropriate probing questions.
The specific probing questions enabled the participant to better understand the question in
order to answer with a yes or no.

If the probing questions were answered "no" the researcher considered the answer
to the original PDC checklist question as a "no". If the probing questions were answered
"yes" the researcher considered the answer to the original PDC checklist question as a
"yes." All PDC verbal responses were recorded by the researcher on the PDC form.
Only one researcher collected all of the information to insure reliability.

At the completion participants were given a list of postpartum depression
resources (see Appendix 1). Participants were thanked for their involvement, given a
baby gift, and escorted back to the waiting room. The baby gift consisted of a bag of
samples including baby wipes, lotion, powder, shampoo, and coupons. The gifts were
donated by Providence Hospital, Southfield, Michigan. The questionnaires, and

screening instrument (EPDS and PDC) were assigned participant code numbers.

24
II B. l E .

Specific procedures were followed to assure that the rights of the study
participants were not violated. These procedures were required and approved by the
Michigan State University Committee on Research Involving Human Subjects (U CRIHS)
(see Appendix J ). Permission to approach subjects for inclusion in the study was
obtained from the obstetric clinics (see Appendix C ). Participation in the study was
voluntary and participants could withdraw from the study at any time without penalty.
Written consent from the participants was obtained. A code number was assigned to each
returned questionnaire.

In this study screening of symptoms characteristic of postpartum depression
included: loss of control, obsessive thinking, loss of self, loneliness, lack of
concentration, loss of interests, insecurity, lack of positive emotions, anxiety, guilt,
contemplating death, difficulty sleeping, and crying. Both the EPDS and PDC included
questions regarding these symptoms. In this study postpartum depression was the
disorder specifically being screened for in the first six to eight weeks postpartum.

S . 1 I . If . l I

A review of the literature indicated that various sociodemographic and modifying
variables might influence the incidence of postpartum depression. Data was collected on
these sociodemographic, and modifying variables (see Appendix F). Operational
definitions of these variables follow.

Sociodemographic variables: Information was requested on the age of the

respondent, race/ethnic background, level of education, annual family income,

25
employment status, marital status, partnerr/significant other support, planned pregnancy,

parity, type of delivery, complications, history of depression,and family history of
depression.
Instuunsntatirm

The two instruments used were the EPDS and the PDC (see Appendix G & H).
The EPDS is a written paper-pencil, self-report questionnaire containing 10 statements
on symptoms of depression. Each statement has four possible responses. Women were
asked to underline the response that came closest to how they felt during the past week.
A score above a threshold of 9/ 10 in primary care settings indicates women who should
be further assessed for clinical depression. Validation studies advocate using a score of
above 10 to identify women at risk for postpartum depression (Murray &
Carothers,1990). Women scoring above 13 are likely to be experiencing postpartum
depression (Schaper, Rooney, Kay, & Silva, 1994). The EPDS takes less than five
minutes to complete.

The PDC is an 11 item questionnaire with accompanying probe questions, which
is administered orally by a researcher. Responses are used to define women who should
be further assessed for clinical depression. The PDC was designed to be used primarily
as an informal checklist by health professionals in the course of their routine contacts.
Nurses and other health care professionals can go through this brief yes/no list of 11
symptoms with mothers when they come in for an appointment for themselves or their
infants and children. The PDC is a screening device to help identify women who might
be experiencing postpartum depression and might need to be referred for follow up. The

PDC should take no longer than 15 minutes to complete.

26

Women were also asked probing questions about their experiences with the items
on the PDC if they answered yes to the main item (see Appendix H). The suggested
questions are all derived from experiences mothers shared regarding these symptoms in
the two qualitative studies by Beck (1992, 1993).

An understanding of postpartum depression must incorporate mothers'
experiences with symptom distress so that cues and patterns suggesting difficulty in
coping and adaptation to motherhood can be recognized (Affonso, 1992). Questioning
mothers about their experiences with the 11 symptoms on the PDC will potentially
provide nurses with rich data on the meaning mothers attach to the symptoms they are
experiencing as reported on the EPDS.

Sociodemographic and modifying variables were surveyed that may influence
postpartum women. Questions regarding factors associated with postpartum depression
were developed by the investigator based on a review of the literature. The PDC was
developed from two qualitative studies on postpartum depression: a phenomenological
study (Beck, 1992) and on a grounded theory study (Beck, 1993). The reliability and
validity of the EPDS will now be discussed in detail.

The reliability of an instrument can be assessed by utilizing a measure of internal
consistency. The Split-half reliability of the EPDS was found to be 0.88. The
standardized alpha-coefficient for the EPDS was 0.87 (Cox, Holden & Sagovsky, 1987).

The EPDS has satisfactory validity based on content validity. Content validity is
based on judgement and concerns itself with the sampling adequacy of the content area

being measured. No objective measures exist for assuring adequate content coverage of

27

an instrument as the evaluation of content validity is a subjective measure often based on
the judgement of experts in a field or careful planning by the researcher. For this study,
content validity of the EPDS instrument was based on published reviews by experts in the
field of postpartum depression.

Although the EPDS was originally developed on a Scottish sample, it was used by
Schaper, Rooney, Kay, and Silva (1994), to identify postpartum depression in 287 white
women in a midwestem clinical setting. Murray and Carothers (1990), also used the
EPDS in the United States on a community sample of 702 women at six weeks
postpartum using the Research Diagnostic Criteria as a criterion related validin measure
of depression. Using the cut-off score of 12/13 the specificity (true negatives) was 97.5
percent, and the sensitivity (true positives) to minor depression was 52 percent.

Construct validity is the degree to which an instrument measures the construct
under investigation. The EPDS scores of 84 postnatal women were compared with the
Standardized Psychiatric Interview (SPI) scores (Goldberg, Cooper & Eastwood, 1970)
adjusted for somatic symptoms normal to the puerperium, and conducted by a psychiatrist
at about 13 weeks postpartum. A threshold score of 12/13 on the EPDS identified all
women with major depression, and the scale had a sensitivity of 86 percent, specificity of
78 percent, and positive predictive value of 73 percent (Holden & Phil, 1991).

The EPDS has also been validated by other researchers and found superior to the
Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) in
detecting DSM-III major depression in 147 women at six to eight weeks postpartum
(Harris, Huckle, Thomas, Johns & Fung, 1989). The EPDS showed a sensitivity of 95

percent and specificity 93 percent; the Beck Depression Inventory sensitivity was 68

28

percent and specificity 88 percent. A high correlation was also found between the EPDS
and two observer-rated depression scales: the Montgomery-Asberg Depression Rating
Scale (MADRS) (Montgomery & Asberg, 1979) and the Raskin 3 Area Scale for
Depression (Raskin, Schulterbrandt, Reatig & Mekison, 1970) .

The EPDS was mailed to 702 Cambridge, England, women six weeks after
delivery (Murray, 1990). The return rate of 97.3 percent indicated impressive evidence of
the scale's acceptability to postpartum women. The authors concluded that their data
underlined the importance of the EPDS as a tool for identifying postpartum depression,
although the sensitivity (67.7%) was lower than reported by others.

5.9911112

The EPDS has been used routinely to screen for postpartum depression or to
substantiate a suspicion that a woman is depressed. Women scoring above threshold
(9/10) should be assessed further before deciding on treatment. Each statement is rated
on a scale zero to three, and possible scores range from 0-30. Questions numbered three,
five, six, seven, eight, nine, and ten are reverse scored. The total score is calculated by
adding together the scores for each of the ten items. Higher scores indicate the increased
likelihood of depression. In this study the determined threshold is 10 based on previous
studies done. If a woman scores 10 or above further evaluation for depression is needed.

The PDC is a llitem yes/no checklist not intended to be used to make a diagnosis
of postpartum depression. The PDC does not replace a firll psychiatric assessment, but
can be used to define a population that may need further evaluation. No score has ever
been calculated from this checklist that indicates a woman needs a referral for a possible

postpartum psychiatric disorder. However, in this study an answer of yes to a question

29

will be scored as one point. Points will then be added to attain a numerical score.
Researchllesign

The research design was descriptive. The variables were scores on the PDC and
EPDS instruments. The EPDS score is interval level data calculated fi'om a likert scale
and the PDC is also interval data calculated from the number of "yes" answers. A
comparison will be made with the results from the EPDS, a standard measure of
postpartum depression, and the number of items checked yes on the PDC.

was

The major research questions for this study and the statistical procedures utilized
to analyze the data obtained from the study follow.

Research question number one: To what extent are the PDC results and EPDS
scores related? Correlational procedures were used to compare the PDC to the EPDS.
The statistics used to describe and summarize this data was the Pearson r.

Research question number two: What sociodemographic and modifying variables
are associated with elevated depression scores? Data related to the various
sociodemographic and modifying variables is presented using nonparametric statistics
due to the small sample size and the categorical nature of the independent variables. T-
tests for two independent samples, Mann-Whitney U tests for independent samples, and

Kruskal-Wallis one-way analysis of variance statistical procedures were used.

RESULTS/FINDINGS
Intrudmfism
This descriptive study was designed to examine the relationship between the Edinburgh
Postnatal Depression Scale (EPDS) and the Postpartum Depression Checklist (PDC) and
sociodemographic characteristics associated with elevated depression scores. The study
was conducted in three obstetric clinics belonging to the same health maintenance
organization in the midwestem United States.

The sociodemographic questionnaire, the EPDS, and the PDC were administered
by the researcher to 30 women, who were six to eight week postpartum, and were
returning to the clinic for their postpartum visit. All participants completed the
questionnaires individually, although some women had their baby with them. On two
occasions, the babies were irritable or crying during the administration of the PDC. All
information was self-report. None of the women who were approached by the researcher
to participate in the study declined.

11 l . Cl . .

The respondents were asked to provide demographic information about

themselves. The results of the frequency distributions used to summarize socio-

demographic characteristics are presented in Table 1.

30

31
Table l - Demographic Variables (N=30)

—

 

Demographic Variable Frequency Percent
Race/Ethnic Background
Asian 1 3.3
Black/African American 4 13.3
Hispanic 1 3.3
Native American 0 0.0
White (Non-Hispanic) 24 80.0
Other 0 0.0
Marital Status
Married 26 86.7
Single 4 13.3
Spousal Support
Very Supportive 19 63.3
Supportive 1 1 36.7
Education
High School Graduate 6 20.0
Some college 12 40.0
Associate’s Degree 3 10.0
Bachelor’s Degree 7 23.3
Above Bachelor’s Degree 2 6.7
Family Annual Income
$10,000 to $29,999 2 6.7
$30,000 to $49,999 8 26.7
$50,000 to $69,999 8 26.7
$70,000 to $99,999 6 20.0
$100,000 and over 6 20.0
Present Employment Status
Employed Full-time (40 hours/week) 1 1 36.7
Employed Part-time (Less than 40 hours/week) 8 26.7
Homemaker 10 33.3
Not Employed I 3.3
Intentions for Employment
Employment Full-time (40 hours/week) 7 23.3
Employment Part-time (Less than 40 hours/week) 10 33.3
Homemaker 13 43.3

 

The majority of the women in the study were White (non-Hispanic), married with
perceived supportive spouses/significant others, highly educated, employed women with

family incomes above $30,000.

Table 2 - Pregnancy Variables (N=30)

 

 

Pregnancy Variable Frequency Percent
Pregnancy Planned

Yes 21 70.0

N0 _ 8 26.7
Major Complications

Yes 6 20.0

No 23 76.7
Type of Delivery

Vaginal 23 76.7

Vaginal with suction/forceps l 3.3

VBAC 5 16.7

Caesarean 1 3.3
First Baby

Yes 12 40.0

No 18 60.0
Treated for Depression

Yes I 3.3

No 29 96.7
Family History of Depression

Yes 3 10.0

No 24 80.0

 

The majority of the women in the sample had a planned pregnancy (n=21, 70.0%),
with eight (26.7%) reporting their pregnancies were unplanned. Major complications
were reported by 6 (20.0%) women. Their complications included blood clots, bleeding,
small bowel obstruction, diabetes, and high blood pressure.

Twenty-three (76.7%) of the deliveries were vaginal with one (3.3%) vaginal with
suction/forceps, and five (6.7%) vaginal births after caesarean (V BAC). One (3.3%)
woman reported her delivery was caesarean. Twelve (40.0%) of the women indicated this
was their first baby.

Only one(3.3%) of the women had been treated previously for depression. Of the

30 women in the study, three (10%) reported a family history of depression.

33
The women completed the Edinburgh Postnatal Depression Scale (EPDS) (Cox,

Holden, Sagovsky, 1987) and the Postpartum Depression Checklist with Script (PDC)
(Beck, 1995). The first instrument was completed by the participants, with the second
administered as a structured interview. Scores were obtained for both measures. The
results of this analysis are presented in Table 3.

Table 3 - Depression Measures

 

Depression Range

Measure Minimum Maximum

    

The mean score for the EPDS was 6.13 (sd=3.59). The scores on this measure

ranged from O to 12 with a median score of 6. Scores greater than 10 were considered at
risk, with scores less than 10 considered not at risk. Four (13.3%) of the women had
scores greater than 10 indicating they were at risk for postpartum depression. None of
these women’s scores exceeded 13, which would have indicated they had postpartum
depression.

The mean number of items checked off on the PDC was 2.10 (sd=1.77), with a
median number of 2.00. The minimum number of items that were reported was 0 with 6
as the maximum number of items checked off. The specific items that were checked off

are presented in Table 4.

34
Table 4 - Frequency Distribution for Specific Items on the PDC

—

Checklist Item Frequency Percent
Lack of concentration 12 40.0
Loss of interest 2 6.7
Loneliness 12 40.0
Insecurity 8 26.7
Obsessive thinking 5 16.7
Lack of positive emotions 4 13.3
Loss of self 7 23.3
Anxiety Attacks 0 0.0
Loss of control 8 26.7
Guilt 5 16.7
Wneplgea , f g ,_ f g f r r g f f f ,, ,, - _ a.0

   

The two most coMonly cited checklist items on the PDC were lack of
concentration (n=12, 40.0%) and loneliness (n=12, 40.0%). None of the respondents
indicated they were having problems with anxiety attacks or were contemplating death.
The interview also probed into specific situations for each of the checklist items.

Researchflusstiam

Two research questions were posed for this study. These questions were answered
using inferential statistical analyses, with all decisions on the statistical Significance of
the findings made using an alpha level of .05.

W: What is the relationship between the Edinburgh Postnatal
Depression Scale (EPDS) and the Postpartum Depression Checklist (PDC)?

Pearson product moment correlations were used to determine the strength and
direction of the relationship between scores on the EPDS and the PDC. The obtained r

value of .64 (p<.01) was statistically significant indicating the two measures were related.

35
The positive nature of the correlation indicated that higher scores on the EDPS were

associated with a greater number of items listed by the women on the PDC. The value of
.64 indicated a moderately high degree of correlation between scores on the two
instruments. As a result of this analysis, there appears to be a significant positive
relationship between the two measures of postpartum depression.

W}. What socio-demographic characteristics are associated with

elevated depression scores?

The scores on the EPDS were used as the dependent variables in the statistical
analyses used to determine if specific socio-demographic characteristics were associated
with elevated depression scores. Due to the small sample size and the categorical nature
of the independent variables, t-tests for two independent samples, Mann-Whitney U tests
for independent samples, and the Kruskal-Wallis one-way analysis of variance statistical
procedures were used. The choice of the statistical test was based on the number of
respondents at each level of the independent variable. Age was the first socio-
demographic variable that was tested to answer this research question.

The ages of the mothers were divided into two groups, less than 30 and 30 and
older, based on the mean in the distribution of ages. Women naturally fell into one of
two groups under 30 or over 30. A t-test for two independent samples was used to
determine if there was a difference in the scores on the EPDS based on the age of the

mothers. Table 5 presents the results of this analysis.

36
Table 5 - t-Test for Two Independent Samples - Score on EPDS by Age of Mother

 

 

Age of Mother Number Mean SD DF t-Value
Less than 30 years 13 5.15 3.60

28 1.32 (NS)
30 years and older 17 6.88 3.50

The t-value of 1.32 (DF =28, p=.196) obtained for this analysis was not
statistically significant. This finding indicated a trend that women who were less than 30
years of age (m=5.15, sd=3.60) had lower levels of depression than women who were 30
years and older (m=6.88, sd=3.50), although this difference was not statistically
significant.

The race of the mothers were divided into two groups, White (n=24) and
nonWhite (n=6) for the purpose of this analysis. A Mann-Whitney U test for independent
samples was used to test for differences in scores on the EPDS relative to their race.
Table 6 presents the results of this analysis.

Table 6 - Mann-Whitney U Test for Independent Samples by Revised Race of
Respondent

 

 

 

Group Mean SD Mean Rank Z value
White 5.50 3.58 13.94 -1 .95,.
NonWhite 8.67 2.42 21 .75

’p.05

The z-value of -1 .95 (p=.05) obtained for the scores on the EPDS was statistically
significant indicating a difference between the White and nonWhite participants. The
significant difference was supported by an examination of the mean ranks, with White
participants (mean rank=13.94) having lower scores than nonWhite participants (mean
rank=21.75). The mean score for White mothers (m=5.50, sd=3.59) provided additional

support that their scores were significantly lower than the mean score for the nonWhite

37
mothers (m=8.67, sd=2.42).

The marital status of the participant was divided into two groups, married (n=26)
and not married (n=4). A Mann-Whitney test for independent samples was used to
compare the scores on the EPDS by the marital status of the mother. Table 7 presents the
results of this analysis. '

Table 7 - Mann-Whitney U Test for Independent Samples by Revised Marital Status of
Respondent

 

 

Group Mean SD Mean Rank Z value
Married 6.15 3.76 15.58

-.12 (NS)
Not Married 6.00 2.58 15.00

 

The obtained Z value of -. 12 (p=.903) was not statistically significant indicating
that the mothers’ scores on the EPDS did not differ based on their marital status. The
mean score of 6.15 (sd=3.76) on the EPDS for married women was similar to the mean
score of 6.00 (sd=2.58) for the women who were not married.

The women were asked to rate their spouses’ or significant others’ supportiveness
of them in the relationship. Their responses were either very supportive or supportive.
These ratings were used as the independent variable to determine if scores on the EPDS
differed based on the perceived support received by their partners. The results of the t test
for two independent samples. The results of this analysis are presented in Table 8.

Table 8 - t-Test for Two Independent Samples - Score on EPDS by Perceived Level of
Support by Spouse or Significant Other

 

Support of Spouse Number Mean SD DF t-Value

 

Very Supportive 19 5.68 3.64
28 -.82 (NS)
Supportive 1 1 6.9 1 3 .53

 

[/1
H .
lif‘r

f!) I/I

(In

38
The obtained t-value of -.82 (df=28, p=.377) was not statistically significant

indicating that depression scores did not differ based on the perceived level of support
obtained from spouses and significant others. However, the mothers who rated their
support as very supportive (m=5.68, sd=3.64) had lower levels of depression than women
who rated their support as supportive (m=6.91, sd=3.53), although this difference was not
significant.

A Kruskal-Wallis one-way analysis of variance procedure was used to determine
if scores on the EPDS differed based on the educational level of the women. Table 9
presents the results of this analysis.

Table 9 - Kruskal-Wallis One-Way Analysis of Variance - EPDS by Educational Level

 

 

Group Mean SD Mean Rank

High School 8.17 2.9 20.17

Some College 5.33 3.06 13.50

Associate Degree 8.00 5.29 20.17 3.71 (NS)
Bachelor Degree 5.43 3.95 13.93

Above Bachelor 4.50 4.95 12.00

 

The chi square value of 3.71 (df=4, p=.447) obtained on this analysis was not
statistically significant indicating that the depression score did not differ relative to the
educational level of the women in the study. The women who were either high school
graduates or had associates degree had the highest mean depression scores with those
who had completed some college or had educational levels above a bachelor level had the
lowest scores on the EPDS.

Depression scores on the EPDS were compared by the self-reported family

income levels of the respondents using a Kruskal-Wallis one-way analysis of variance.

39
The results of this analysis are presented in Table 10.

Table 10 - Kruskal-Wallis One-Way Analysis of Variance - EPDS by Family Income
Level

 

 

Group Mean SD Mean Rank

10,000 to 29,999 6.50 2.12 16.00

30,000 to 49,999 8.63 2.20 21.63

50,000 to 69,999 5.00 4.24 12.63 7.03 (NS)
70,000 to 99,999 6.33 3.39 16.33

100.000 and over 4.00 3.58 10.17

 

The obtained chi-square value of 7.03 (df=4, p=.134) was not statistically
significant indicating that depression did not differ among the women relative to their
family incomes a trend was noted in that the women with family incomes between
$30,000 and $49,999 (m=8.63, sd=2.20) had the highest scores on the EPDS, while those
with incomes above $100,000 (m=4.00, sd=3.58) had the lowest scores.

The women’s depression scores were compared by the women’s present
employment status and their intentions for employment in the next six months. The
Kruskal-Wallis one-way analysis of variance procedures that were used for this purpose

are presented in Table 11.

40
Table 11- Kruskal-Wallis One-Way Analysis of Variance - EPDS by Employment Status

 

 

Group Mean SD Mean Rank

Present Employment Status

Employed Full-time 5.09 3.62 12.95

Employed Part-time 6.13 3.91 15.69 1.76 (NS)
Homemaker 7.18 ’ 3.34 17.91

 

Intentions for Employment in the Next Six Months

Employed Full-time 6.00 3.42 15.00
Employed Part-time 5.00 3.97 13.00 1.64 (N S)
Homemaker 7.08 3.59 17.69

 

The comparisons regarding present employment status (2 = 1.76, df=2, p=.415)
and intentions for employment in the next six months (2:1.64, df=2, p= .439) were not
statistically significant. These findings indicated that depression levels did not differ
among the women based on their employment status, either currently or in the next six
months. However, women who were planning to remain home in a homemaker role had
the highest scores on depression.

The women’s depression scores were compared relative to whether they had had
complications during their pregnancy. Six of the 30 women reported complications. The
two groups, complications and no complications, were compared on their EPDS scores
using a Mann-Whitney test for independent samples. The results of this analysis are

presented in Table 12.

41

Table 12 -Mann-Whitney Test for Independent Samples - EPDS by Pregnancy
Complications

 

 

Group Mean SD Mean Rank Z value
Complications 5.83 3.37 14.00

. . -.32 (NS)
N0 Complications 6.00 3.64 15.26

 

The resultant Z value of -.32 (p=.773) provided on the Mann-Whitney test for
independent samples was not statistically significant. This finding indicated that women
who had complications during pregnancy (m=5.83, sd=3.3 7) had similar scores on the
EPDS as women who did not have complications (m=6.00, sd=3.64).

The responses to the question, was this your first baby, “yes” or “no,” was used as
the independent variable in a t-test for two independent samples. The scores on the EPDS
were used as the dependent variable in this analysis. Table 13 provides the results of this
analysis.

Table 13 - t-Test for Two Independent Samples - Score on EPDS by First Baby

 

 

First Baby Number Mean SD DF t-Value
Yes 12 4.92 3.23

28 -1.55 (NS)
No 18 6.94 3 .67

 

The obtained t-value of—1.55 (df=28, p=.132) was not statistically Significant
indicating that mothers did not differ in their levels of depression based on whether or not
this baby was their first child. The women who had had their first baby (m=4.92,
sd=3.23) had lower levels of depression than mothers (m=6.94, sd=3.67) who had more
than one child.

The women were asked if their pregnancy was planned. Their responses to this

question were used as the independent variable in a Mann-Whitney U test for

42

independent samples. The scores on the EPDS were used as the dependent variable. Table
14 presents the results of this analysis.

Table 14 - Mann-Whitney Test for Independent Samples by EPDS scores by Planned
Pregnancy

 

 

Group Mean SD Mean Rank Z value
Planned Pregnancy 6.00 3.90 15.12

-.12 (NS)
Unplanned Pregnancy 5,88 2.53 14.69

 

The obtained Z value of -.12 (p=.905) was not statistically significant indicating
that the depression scores did not differ based on whether their pregnancy was planned or
unplanned. The mean scores for the two groups were similar with women whose
pregnancy was planned (m=6.00, sd=3.90) having scores that were very close to the

women who had unplanned pregnancies (m=5.88, sd=2.53).

DISCUSSION
Introduction

The Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum
Depression Checklist (PDC) were found to be significantly correlated (r=.64, p>.Ol).
This is the first study to attempt to quantitatively score the PDC and compare the results
to EPDS results . This positive correlation supports the PDC's use in practice as a
screening method for postpartum depression. The four women who had scores greater
than 10 on the EPDS, a score indicating risk, were referred to their physician for further
evaluation. All participants gave verbal permission for results to be shared with the
physician if indicated.

In relationship to the PDC probing questions, none of the respondents answered
yes to having anxiety attacks or to have contemplated death. However, none of the
women had an EPDS score that exceeded 13.

The sociodemographic characteristic that was found to be significantly related to
elevated EPDS scores was being non-white (z=-1.95, p=.05). Six participants were non-
white, four were Black/Afiican Americans, one Asian, and one Native-American. In the
study by Schaper, Rooney, Kay, and Silva (1995) that used the EPDS in the United
States, race was not analyzed because 95% of the women in the study were White.
However, numerous studies have reported higher levels of symptoms of depression in
women and Blacks (rather than Whites) (Jones-Webb & Snowden, 1993).

None of the identified risk factors examined in this study demonstrated a

significant association with an elevated EPDS score. These factors were age, marital

43

44
status, partner/significant other support, level of education, income level, employment

status, planned pregnancy, parity, complications, type of delivery, history of depression,
and family history of depression.

Of the four women with EPDS scores greater than 10, two were non-White, none
had education beyond an associates degree, three were homemakers while one was
employed full-time, and one had intermittent hypertension during her pregnancy. All
four women were from middle income levels, were married, percieved their partner/
significant other as supportive,had a planned pregnancy, had a vaginal delivery, none was
this their first baby, and none had a history of depression or family history of depression.
The mean age for these women was 30. These characteristics were reflective of the
sociodemographic results found in the study.

5 . 1 l . I 1

Although not significant, the following trends were noted in the
sociodemographic correlations with the EPDS. In the study, women who had a higher
depression score on the EPDS tended to be 30 years and older. Women less than 30 years
old had a mean score of 5.15 on the EPDS (SD=3.60) while those 30 years and older had
a mean score of 6.88 on the EPDS (SD=3.70). In contrast to the results of the current
study, Gotlib, Whiffen, Mount, Milne, and Cordy (1989) found postpartum depression to
be unrelated to age.

In this study marital status was not significant nor was level of support obtained
from spouses or significant others. However, there was a negative correlation between a
woman's percieved support from her partner/significant other and levels of depression on

the EPDS. This supports previous literature, which showed that an unstable relationship

45
with the husband or partner and lack of support is predictive of postpartum depression

(Romito, 1989). Schaper, Rooney, Kay, and Silva (1994) also found women who were
separated, divorced or widowed and who percieved marital instability to be at higher risk
for postpartum depression.

Women who had completed some college or had educational levels above a
bachelor level and those with incomes above $100,000 had the lowest scores on the
EPDS. Inadequate financial resources and dissatisfaction with education are factors that
have correlated positively with postpartum depression in previous studies (Posner,
Untennan & Williams, 1985).

Women who were planning to remain home in a homemaker role had the highest
scores on depression. This was supported by a previous study that found women who
listed their occupations as housewife were at a significant higher risk for developing
postpartum depression (Gotlib, Whiffen, Mount, Milne & Cordy, 1989).

Although not significant, complications during pregnancy were not in general
indicative of higher depression scores. Oakley (1980) and Paykel , Emms, Fletcher, and
Rassaby (1980) in postpartum studies of depression found no association with obstetric
difficulties and complications. Mothers who had more than one baby had slightly higher
depression scores. On the EPDS no difference was found based on whether the
pregnancy was planned or unplarmed. Schaper, Rooney, Kay, and Silva (1995) also
found parity and unplanned pregnancy to demonstrate no significant association with
elevated EPDS scores.

In this study, all deliveries were vaginal except for one caesarean. Only one

woman had been treated prior for depression, and three had a family history of

46
depression. This data could not be analyzed due to the small sample size. Previous

studies have found that those with a history of depression or family history of depression
to be more likely to be at risk for depression (Schaper, Rooney, Kay & Silva, 1995;
Watson, Elliot, Rugg & Brough, 1984; and O'Hara, Neunaber & Zekoski, 1984).

The current study findings indicate that postpartum depression is essentially
unrelated to major sociodemographic variables with the sole exception of women who
were non-white. These results would suggest that postpartum depression is not related to
a consistent sociodemographic pattern.

The EPDS was acceptable to the women, easily understood, convenient to
administer, took about five to ten minutes to complete, could be completed in the waiting
room by the patient, and was easy to score for immediate identification of women at risk
for postpartum depression. Less information was obtained with the EPDS than with the
PDC. However, ideally once women have completed the EPDS, women should always
be given the chance to discuss their feelings ( Holden & Phil, 1991).

The PDC was acceptable to women and easy to administer. Furthermore, actually
talking about postpartum depression broke down barriers regarding mothers shame,
embarrassment and denial associated with postpartum depression. If used appropriately
the questions should encourage a dialogue between the patient and health care giver
(Beck, 1995). As in this study, many times the participants answering PDC questions
would verbalize their rationale of why they were experiencing a symptom. The major
advantage of the PDC was the interaction generated between the health care provider and

the woman. This type of interaction generates more information and builds a trusting

47
relationship between the patient and health care provider.

The PDC is more time consuming, has no established quantitative scoring, and
demands the APNS time for verbal administeration in a private area. Confidentiality was
more difficult to maintain with the PDC because it was administered orally. Also
frequent clarification of misunderstood meanings had to be made by the researcher. In
these instances the researcher proceeded to the appropriate probing questions. Special
difficulty also existed in the participants understanding of the words like "cobwebs",
"fogginess", and "robot."

The EPDS or PDC are both suitable for postpartum depression screening. The
use of the tools would depend on the health care providers level of knowledge and
comfort, availability of space, and time constraints. At this time the author would
recommend the EPDS to be used in clinical practice until the PDC is further refined.

Amatisms

The investigator made the following assumptions in the study.

(1) Postpartum women are able and willing to honestly answer the questions regarding
postpartum depression and its impact on their life.

The following limitations were noted for this study.

(1) The convenience sample drawn from a midwestem suburb limits the population to
which the study results can be generalized and is not representative of all postpartum
women.

(2) The sample size was small and required the use of nonparametric statistics in many

cases.

48
W
This study can be a starting point for further development of the PDC as a
quantitative instrument for measuring risk of postpartum depression. With further
research a cut-off score on the PDC checklist could be determined to indicate those at risk
for postpartum depression or more likely to be experiencing postpartum depression. Also
a rating system for the PDC probing responses measuring severity and/or frequency of
symptoms may be developed in the future. Wording could also be changed to clarify
words like cobwebs, fogginess, and robot.

Revalidation of the PDC in other clinical settings must be carried out because a
convenience sample of basically White, upper-income, highly educated women was
used, therefore, generalizability of the findings is limited. Additional research using a
more diverse population is needed to explore the generalizability of these findings.
Furthermore, the study should be repeated using a larger sample size to look at multi-
factorial combinations of sociodemographic variables and their contribution to depression
using a multiple regression. The sociodemographic information gathered can be added to
the already existing data as a source of comparison in future postpartum depression
research.

I 1° . E i 1 I P. . 1 1
Advanced practice nurses (APNS) in primary care need to assess all women
routinely for postpartum depression. The author would recommend using the EPDS as an
adjunct to clinical judgement in assessing patients for postpartum depression. Screening
would identify women likely to have postpartum depression and women at risk for

developing postpartum depression.

49

It is important to note the potential risk of a mother harming herself or infant also
must be assessed. If a risk exists then immediate intervention by the APN must be taken.
Family involvement is certainly indicated as is potentially immediate psychiatric
evaluation and hospitalization, and contracting with the patient if she is to return home.
These women must be followed-up in a timely manner that takes into account their needs.
Ideally a protocal would be developed to facilitate referral and follow-up. Health care
providers are more apt to screen for conditions if they think they know what to do once
the condition is found.

Early nursing interventions should be implemented with women experiencing or
at risk for postpartum depression to prevent long-term effects on mothers and their
children. Most women with postpartum depression do not require psychiatric
intervention (Holden & Phil, 1991). Research findings support the view that therapeutic
listening and extra support by a professional may be sufficient to prevent women from
developing postpartum depression (Holden, Sagovsky & Cox, 1989).

In a sample of ten mothers who experienced postpartum depression, Beck (1995a)
identified seven themes that illustrated nurses' caring for mothers with postpartum
depression. These themes were 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, providing continuity of care, and understanding what
the mothers were experiencing. The themes identified should be incorporated into APN
practice when caring for a woman experiencing postpartum depression.

APNS possess the skills to provide appropriate counseling interventions. The

50
APN can normalize the postpartum depression, acknowledge and validate the woman's

feelings, counter ideas of self-blame, let her know she is not alone and that the feelings
she is experiencing will end, and that help is available for postpartum depression.
(Holden, Sagovsky & Cox, 1989). Other interventions may include medical management
(antidepressants), education, connection with postpartum depression support groups,
and/or referral to a psychiatrist. Also the development of a postpartum resource list to
distribute to all postpartum women and antenatally when appropriate is highly
recommended (Beck, 1995a). These interventions are all within the realm of the APN.

Furthermore, postpartum depression scores can be used when assessing a
woman's risk of postpartum depression in future pregnancies. Recurrence has been
featured prominently in the literature (Schaper, Rooney, Kay & Silva, 1994). Data
summarized by Harding (1989) indicated that women with postpartum depression had a
30 to 50% chance of suffering another episode of postpartum depression after a
subsequent pregnancy.

QQnQIEEIQn

Due to the denial, shame, and embarrassment that often keep women with
postpartum depression from seeking help, the rate at which postpartum depression occurs,
and the detrimental impact it has on the mother and child, the need for early screening
with the EPDS and/or PDC is essential in the secondary prevention of postpartum
depression. This study supports these facts with four (13.3%) postpartum women
identified at risk for postpartum depression and the sociodemographic variables not
reliable in the identification of postpartum depression. Therefore, it is important to

screen all women for postpartum depression.

APPENDICES

APPENDIX A

II I_l_I III I!

3:1! "I

WEST?! OF

DE ISLAND Appendix A

Postpartum Depression Checklist Consent
Marc‘ 22, 1996
Mary Pat Mullen, RN
Providence Hospital
State of Michigan
Dear Mary Pat:
You have my permission to use my Postpartum Depression Checklist that had
been published in JQQNN this past summer. I am delighted that you will be
using it in your masrer’s thesis. Good luck in your research endeavor!
Sincerely,
Laws”: 31a...o 2:32.497,
Cheryl Tatano Beck, DNSC, CNM, FAAN
Professor '
CTszrd
the Hawaii"! course orzwrsmc 51
M: W 1‘ "' White Hall. Kingston. Rhode Island 03381-0814
Ifimdwm-‘J

'wl 9;":qu acme. Phone 401-752-2766 Fax: 401-792-2061

APPENDIX B

Appendix B

Letter of Introduction

Dear

I am a nurse at XXXXXXXXXXX, XXXXXXXXXXX, and currently doing an
externship with Dr. XXXXXXXXXX to complete requirements for a Master's degree in
Nursing from Michigan State University.

Currently, I am also conducting research regarding postpartum depression. This
includes the completion of three questionnaires by women six to eight weeks postpartum.
I would like, with your permission, to approach your postpartum clients in the waiting
room for inclusion in my study.

The questionnaires will take only approximately twenty minutes of your client's
time for completion. Women who have participated in the study have found it to be an
interesting and worthwhile experience. A copy of the client consent letter and
questionnaires accompany this letter for your review.

If you have any questions regarding the material, or to reply to my request, please
feel flee to contact me at the number given
below. Thank you for your time and consideration.

Sincerely,

MaryPat Mullin R.N.,B.S.N.

MSN Candidate

Michigan State University

College of Nursing, Graduate Program
Family Clinical Nurse Specialist Program
Phone: (313) 432-2612

52

APPENDIX C

Appendix C

Physician Permission

February 29, 1996

I have given Mary Pat Mullin, a graduate nursing student at
Michigan State University, permission to approach my clients who
are six to eight weeks postpartum for inclusion in the study of
postpartum depression.

The study involves participants answering a series of written
and oral questions after consent has been ascertained. All the
participants’ responses on the study questionnaires will remain
strictly confidential. I have been given a copy of the client
consent and questionnaires to be used.

03.1% 6. AW

‘S-i/gnature ff Phys lcian

APPENDIX D

February'29, 1996

I have given Mary Pat Mullin, a graduate nursing student at
Michigan State University, permission to approach my clients who
are six to eight weeks postpartum.for inclusion in the study of
postpartum depression.

The study involves participants answering a series of written
and oral questions after consent has been ascertained. All the
participants' responses on the study questionnaires will remain
strictly confidential. I have been given a copy of the client
consent and questionnaires to be used.

\r-‘z/

Signature'of Physician Date

   

 

col
ow.

C01

Appendix D

Introduction Script

HelloIam Name .

I am a registered nurse and graduate nursing student at Michigan State University
collecting data on postpartum depression. I would appreciate it today, if you could fill-
out a questionnaire and answer a few questions to assist me with this study.

It takes approximately 20 minutes to complete, and all information shared is
confidential.

YES /NO. Thank you for your time and consideration.

57

APPENDIX E

Appendix E

Patient Consent

The purpose of this study is to gather information on postpartum depression screening. I
understand that:

l.

2.

9

10

The written and oral questionnaires will take approximately 20 minutes to complete.

Participation in the study or withdrawal from the study, will in no way effect the
health care my family or I receive.

I understand that no claims of beneficial therapeutic or educational effects have been
made.

I understand that reading and answering questions related to postpartum depression
may cause emotional discomfort.

If I am distressed as a result of this interview, I know I can obtain help from thelist
of postpartum depression resources given to me.

I may discontinue my participation at any time.

All information obtained will be treated with strict confidentiality and the identity of
participants will remain strictly anonymous.

1 have been given an opportunity to ask questions about the study.

. Results will be made available to me upon written request.

. Upon completion I will be given a free baby gift.

My consent to participate is freely given, without coercion by anyone.

 

Signature of participant Date

 

Signature of witness Date

If you have any questions or concerns that may be raised by participating in the
study please feel free to contact me at (313) 432-2612.

58

APPENDIX F

Appendix F
Sociodemographic Questionnaire
Please answer each question to the best of your ability.

1. What is your race/ethnic background? (Please circle one).
a. Asian
b. Black/African American
c. Hispanic
(1. Native American
e. White (non Hispanic)
f. Other (Specify)

 

2. What is your marital status? (Please circle one).
a. Married
b. Single
c. Separated
d. Divorced
e. Widowed

3. If you have a spouse or significant other, how would you describe their
supportiveness of you in the relationship?

(Please circle one).

a. Very supportive c. Unsupportive

b. Supportive (1. Very unsupportive

4. What is the Meat level of education you completed?
(Please circle one).

a. Some high school (1. Associates degree
b. High school graduate e. Bachelors degree
c. Some college f. Above Bachelors

5. What is your family's annual income? (Please circle one).

a. $9,999 and under d. $50,000 to $69,999
b. $10,000 to $29,999 e. $70,000 to $99,999
c. $30,000 to $49,999 f. Above $100,000

6. What is your present employment status? (Please circle one).
a. Employed full time (40 hours/week)
b. Employed part time (Less than 40 hours/week)
c. Homemaker
d. Not employed

59

7. What are your intentions for employment in the next six months time? (Please circle
one).
a. Employment full time (40 hours/week)
b. Employment part time (Less than 40 hours/week)
c. Homemaker

8. Was your pregnancy planned? (Please circle one).
a. Yes
b. No

9. Did you have any major complications with your pregnancy?
(e. g. high blood pressure, diabetes, etc.)? (Please circle
one).

a. Yes
b. No
If yes, please describe the complications you had: _

 

10. What type of delivery did you have? (Please circle one).
a. Vaginal
b. Vaginal with suction/forceps
c. VBAC
d. Caesarean

11. Is this your first baby? (Please circle one).
a. Yes
b. No

12. Was there a time in your life when you were treated for depression. (Please circle
one).
a. Yes
b. No
If yes, when (Please indicate year). Also who did you see:
a. Physician/Psychiatrist (Please circle one).
b. Counselor/Therapist
c. Minister/Priest
d. Other —

 

13. In your family is there a history of depression? (Please circle one).

a. Yes
b. No
c. Unknown

60

APPENDIX G

Appendix G

Edinburgh Postnatal Depression Scale

Edinburgh Postnatal Depression Scale. (From Cos 1L. Holden 1M. Sagovsky R. Detection of postnatal
depression: Development of the lO-itern Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-786.)

 

Today‘s date Baby’s age
Baby's date of birth _ Birth weight '
Mather's age Baby‘s place in family: I 2 3 4 5 6 7

 

HOW ARE YOU FEELING?

As you have recently had a baby, we would like to know
how you are feeling now. Please underline the answer
which comes closest to how you have felt in the past 7
days. not just how you feel today.

Here is an example. already completed:

I have felt happy:
Yes. most of the time
Yes. some of the time
No. not very often
No. not at all

This would mean: “I have felt happy some of the time"
during the past week. Please complete the other questions
in the same way.

IN THE PAST SEVEN DAYS

1. l have been able to laugh and see the funny side of
things:
As much as i always could
Not quite so much now
Definitely not so much now
Not at all

2. l have looked forward with enjoyment to things:
As much as I ever did
Rather less than I used to
Definitely less than I used to '
Hardly at all

3. l have blamed myself unnecessarily when things went
wrong:
Yes. most of the time
Yes. some of the time
Not very often
No. never

 

4

5

5

. l have felt worried and anxious for no very good reason:
No. not at all
Hardly ever
Yes. sometimes
Yes. very often

. l have felt scared or panicky for no very good reason:
Yes. quite a lot
Yes. sometimes
No. not much
No. not at all

. Things have been getting on top of me:
Yes. most of the time I haven't been able to cope at all
Yes. sometimes I haven‘t been coping as well as usual
No. most of the time I have coped quite well
No. l have been coping as well as ever

. l have been so unhappy that l have had difficulty sleeping:
Yes. most of the time
Yes. sometimes
Not very often
No. not at all

. l have felt sad or miserable:
Yes. most of the time
Yes. quite often
Not very often
No. not at all

. l have been so unhappy that l have been crying:
Yes. most of the time
Yes. quite ofien
Only occasionally
No. never

. The thought of harming myself has occurred to me:
Yes. quite often
Sometimes
Hardly ever
Never

 

61

APPENDIX H

Appendix H

Postpartum Depression Checklist With Probes

 

 

ITEM

 

 

Question: Lack of Concentration

 

Probes: Are you experiencing difficulty concentrating?

 

: Does your mind seemed to be filled with cobwebs?

 

: Does it seem at times like fogginess sets in?

 

Question: Loss of Interests

 

Probes: Do you feel your life is empty of your previous interests and goals?

 

 

: Have you lost interest in your hobbies that used to bring you pleasure and
enjoyment?

 

 

Question: Loneliness

 

Probes: Are you experiencing feelings of loneliness?

 

: Do you feel as though no one really understands what you are
experiencing?

 

: Do you feel uncomfortable around other people?

 

 

 

: Have you been isolating yourself from other people?

 

Question : Insecurity

 

: Have you been feeling insecure. fragile. or vulnerable?

 

 

 

-: Does the responsibility of motherhood seem overwhelming?

 

Question: Obsessive Thinking

 

Probes: Is your mind constantly filled with obsessive thinking such as. "What‘s

wrong with me?“ “Am i going crazy?” ”Why can't i enjoy being with my
baby?”

 

: When trying to fall asleep at night, is your mind racing with repetitive
thoughts?

 

Question: Lack of Positive Emotions

 

Probes: Are you experiencing feelings of emptiness?

 

: Do you feel like a robot just going through the motions?

 

 

 

 

: When caring for your infant/child. do you feel any joy or love?

 

62

 

 

Yes

No

 

 

 

Question: Loss of Self

 

Probes: Do you feel as though you are net the same person you used to be?

 

 

: Are you afi'aid that your life will never be normal again? '

 

 

Question: Anxiety Attacks

 

Probes: Are you experiencing uncontrollable anxiety attacks?

 

: Are you experiencing periods of palpitations. chest pains. sweating. or
tingling hands?

 

 

: When going through an anxiety attack, do you feel 3 though you're losing
your mind?

 

 

Question: Loss of Control

 

Probes: Do you feel you are in control of your emotions and thoughts?

 

 

 

: Are you experiencing loss of control in any aspects of your life?

 

Question: Guilt

 

Probes: Are you feeling guilty because you believe you are not giving your
infant/child the love and attention he’she needs?

 

: Are you experiencing guilt over thoughts of harming your infant/child?

 

 

 

: Do you feel you are a good mother?

 

Question: Contemplating Death

 

Probes: Have you experienced thoughts of banning your self?

 

 

 

 

: Have you been feeling so low that the thought of leaving this world was
appealing to you?

 

 

APPENDIX I

Appendix I

Postpartum Depression Resources

Local Resources:

Postpartum Depression Support Group
Providence Hospital, Southfield, MI

First and third Tuesday of the month, 7:30 pm.
(810) 737-3612

Postpartum Moms' Support Group

Reichert Bldg, Ann Arbor, MI

First and third Tuesday of the month, 5:30 pm.
(313) 712-5400 or (800) 231-2211

International Resources:

Depression After Delivery

Support Group & Hotline Information
PO. Box 1282

Morrisville, PA 19067

(215) 295-3994

(800) 944-4PPD

Postpartum Support International
927 North Kellogg Avenue
Santa Barbara, CA 9311 1

The Marce' Society

c/o Michael O'Hara Phd
Department of Psychology
University of Iowa

Iowa City, IA 52242
(319) 355-24520

Postpartum Adjustment Support Services (PASS-CAN)
PO. Box 7282

Oakville, Ontario L6] 6C6 Canada

(905) 844-9009

Educational Resources:

Santa Barbara Birth Resource Center
2255 Modoc Road

Santa Barbara, CA 93101

(805) 682-7529

64

 

APPENDIX J

 

OFFICE OF

RESEARCH

. AND
GRADUATE
STUDIES

University Committee on
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Human Sublects
(UCRIHS)

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232 Administration Building
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517/355-21w
FAX: 517/432-1171

The Midtiaan Sate University
IDEA is Instinmnal Diversity.
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MICHIGAN STATE
0 N l v E a s I T Y

February 27, 1996

 

TO: Mary Pat Mullin
415 Orchard Ridge
South Lyon, MI 48178

RE: IRB#: 96-076

TITLE: POSTEBETUM DEPRESSION SCREENING WITH THE EPDS
AND .

REVISION REQUESTED: N/A

CATEGORY: l-C

APPROVAL DATE: 02/27/96

The university Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete.. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately

rotected and methods to obtain informed consent are appropriate.
ggerefore. the UCRIHS approved this progect and any revzsrons listed
a ove.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be and one year must use the green renewal
form (enclosed with t e original a proval letter or when a_
project is renewed) to seek u date certification. There is a
max1mum of four such expedite renewals ossible. Investigators
wishin to continue a project beyond tha time need to submit it
again or complete rev1ew.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects. rior to initiation of t e change. If this is done at
the.time o renewal. please use the green renewal form. To
rev1§e an approved protocol at an other time during the year,
send your written request to the. CRIHS Chair. requesting revised
approval and referenc1ng the project's IRE # and title.. Include
in our request a description of the.change and any reVised
ins ruments. consent forms or advertisements that are applicable.

PROBLENS/

CHANGES: Should.either of the followin arise during the course of the
work. investigators must noti UCRIHS promptly: (1) problems
(unexpected side effects, comp aints. e c ).1nvolv1ng uman
subjectsoor (2).changes in the research enVironment or new
information indicating greater risk to the human sub ects than
eXisted when the protocol was preViously reviewed an approved.

If we can be of any.future_help, please do not hesitate to contact us
at (517)355-2180 or FAX (517)4 2-1171.

Sincerel

 
  

vid 3. Wright. Ph.D.'
ucnms Chalr '

DEW:bed

cc: Linda Beth rieeje_

65

LIST OF REFERENCES

LIST OF REFERENCES

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68
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69

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/

7O

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