‘3‘ m1 J1 |.l‘ 5.3... . ‘ ‘ _ , ,1. . ”Lag. . .r Lxm‘ay 3d? 1. ‘ \fl . Ci. 1 {a mg. n; A? m1..».i.... 1 v: yumwuahafi9 .. .24.: r , .hfl. 4-) H4: . I a and t1. 2 .s a!" . 1.31.... 303”»? {it‘lisx‘h Ill .5 5.1).!!! .157-..) p 1-37.5.1)... . t.fi...l£...J THESiS W‘ll‘lllllll\ LI 3 RARY \\\\\\\l\4\\1 2g\\\3\\‘\l\¥1‘7\:l\§ 2465 Michigan State Unlverslty This is to certify that the thesis entitled LOSS IN A MOTHER' S SOCIAL SUPPORT NETWORK AND PEEHE RELATION TO DEPRESSION IN THE POSTPARTUM PERIOD presented by l Marianne Jurczyszyn Ball has been accepted towards fulfillment of the requirements for M . S .N . degree in NURSING way/w Major professor Date /‘14‘3LW1{737 0.7639 MS U is an Affirmative Action/Equal Opportunity Institution PLACE IN RETURN Box to remove this checkout from your record. TO AVOID FINE return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE I DATE DUE DATE DUE 7%5m1fi3 ‘ “ .‘l ‘2: ZUIU Iflflé’ 0 1M Wu LOSS IN A MOTHER'S SOCIAL SUPPORT NETWORK AND THE RELATION TO DEPRESSION IN THE POSTPARTUM PERIOD BY Marianne Jurczyszyn Ball A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 1998 ABSTRACT LOSS IN A MOTHER'S SOCIAL SUPPORT NETWORK AND THE RELATION TO DEPRESSION IN THE POSTPARTUM PERIOD BY Marianne Jurczyszyn Ball New motherhood is a time of transitions and dependencies with new roles and emotions. During this period a woman surrounds herself with those persons she perceives as integral to her support, her social support network (SSN). During postpartum, four to fifteen percent of new mothers experience Postpartum Depression (PPD). This non- experimental correlational study, guided by Roy's Theory of Adaptation, was a secondary analysis exploring support network relationship and loss during the prenatal and/or postpartum period and its impact on depressive symptomatology. The sample was 33 low income pregnant women from Jackson County attending a not—for-profit prenatal clinic, and reporting at least two persons in their SSN. No significant association was identified between loss in the network and depressive symptomatology with the prenatal CES- D as covariate. Concepts related to recognition of risk factors must continue to be explored to decrease PPD and its cost, and increase healthier mother-infant/family relationships. The APN must focus on screening techniques for depression while interacting with mothers during prenatal and well baby visits. To Barry My friend, lover, and husband of 22 years. You are the reason. iii ACKNOWLEDGMENTS With deep gratitude to my thesis chair, Rachel Schiffman, R.N., Ph.D for her encouragement, wisdom, and guidance; and to Linda Spence, R.N., Ph.D. and Mildred Omar, R.N.C., Ph.D., for their patience and expertise during my journey. iv TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . . . . vii LIST OF FIGURES . . . . . . . . . . . . . viii INTRODUCTION . . . . . . . . . . . . . . . 1 STATEMENT OF THE PROBLEM . . . . . . . . . . . 4 CONCEPTUAL DEFINITIONS. . . . . . . . . . . . 10 Social Support Network . . . . . . 10 Loss in the Social Support Network . . . . 16 Postpartum Depressive Symptoms . . . . . . . 16 Depressive Symptoms . . . . . . . . . 16 Clinical Depression . . . . 17 Measurements of Depressive Symptomatology . . 18 Characteristics of Postpartum Depressive Symptomatology . . . . . . . . . . . 20 CONCEPTUAL FRAMEWORK . . . . . . . . . . . . 24 REVIEW OF THE LITERATURE . . . . . . . . . . . 32 Critique of the Literature. . . . . . . . . 37 METHODS. . . . . . . . . . . . . . . 39 Research Design . . . . . . . . . . . . 39 Sample . . . . . . . . . . . . 40 Operational Definition . . . . . . . . . . 42 Instruments. . . . . . . . . . . . 44 Data Collection Procedure . . . . . . . . . 47 Data Analysis . . . . . . . . . . 47 Protection of Human Subjects . . . . . . . . 48 Assumptions and Limitations . . . . . . . . 48 RESULTS. . . . . . . . . . 50 Analysis of Research Question. . . . . . . . 50 DISCUSSION. . . . . . . . . . . . . . . . 51 Implications . . . . . . . . . . . 53 Conceptual Framework . . . . . . . . . 53 Existing Literature . . . . . . . . . 55 IMPLICATIONS FOR ADVANCED PRACTICE AND PRIMARY CARE RECOMMENDATIONS FOR FURTHER RESEARCH SUMMARY. APPENDICES. . Data Collection Method Current UCRIHS Approval. . UCRIHS Approval for Original Study Instruments. . Norbeck Social Support Questionnaire: Support Network Data Network Loss Data . . Center for Epidemiologic Studies DepresSion Scale . . . . . . . . . . . LIST OF REFERENCES vi 57 6O 61 63 63 64 65 66 66 67 68 69 LIST OF TABLES Table 1. Frequency and Percent of Demographic . . 41 Characteristics of Sample Table 2. Means and Standard Deviations for Depression Scores of the Three Loss Groups 51 vii LIST OF FIGURES Figure 1 - Adaptation of Roy's Theory of Person as an Adaptive system showing the relationship between the loss of a significant member in a mother's Social Support Newtwork and depressive symptomatology 26 viii Introduction Women experience many transitions going from a prepregnant state to one of motherhood. In this multifaceted, changing role, multiple and complex factors influence outcomes of pregnancy. During this transitional phase, seventy—five percent of new mothers experience varying degrees of depressive symptomatology in the postpartum period (Kumar, 1990). Exploring loss in a mother's support network and the impact on depressive symptomatology may aid in proactive management and prevention of depression during postpartum. Pregnancy and new motherhood are a time of transitions and dependencies. New roles, responsibilities and emotions surround the mother. During pregnancy, a woman prepares herself and those with whom she is closest for the coming birth of a new family member. Relational behavior dynamics of the family and support system affect a woman as she progresses through the pregnancy. Rubin (1984) examined developmental tasks through which women advance during the antepartum period and found ensuring acceptance of the pregnancy and birth by the family and those closest to her, to be important in the transition to, and acceptance of, the maternal role. It follows that appropriate support from those close to the mother during the antepartum period may play a key role in positive 2 psychosocial outcomes and the transition a woman makes into motherhood after her child is born. It has been recognized that transitions or changes in one's life are generally better managed when support from others is given (Thoits, 1984). Therefore, the majority of women work hard at the task of establishing a reliable support network to see them through the pregnancy and the challenges of role acceptance and motherhood that await them after the birth (Rubin, 1984). A key issue to the mother's adaptation to changes brought about by pregnancy/motherhood and role, is the support given by those who are significant to the mother, her convoy or social support network (Gjerdingen & Chaloner, 1994; Kahn & Antonucci, 1981; Zachariah, 1994). It is the husband/partner, the woman's mother, family, and close friends who have exhibited sensitivity to, and perception of the mother's needs that are generally chosen for the network (Rubin, 1984). The social support resource provided by the network members has not been found to dramatically alter the stressors of pregnancy, but is thought to be protective in nature and moderate the impact of stress, while facilitating coping for the mother (Aaronson, 1989). Significant life changes, like those of pregnancy and motherhood, for women with high psychosocial resources have been found to modify potentially pathological effects from life stresses and those women with low resources demonstrated greater 3 depressive symptoms (Norbeck & Tilden, 1983). Therefore, deficits in social integration and lack of reliable alliances with others have been found to place the mother at risk for postpartum depression (Collins, Dunkel-Schetter, Lober, & Scrimshaw, 1993; Logsdon, McBride, & Birkimer, 1994). It appears to be adequate support resources that enables the mother to transition through life's stressors. Pregnancy and motherhood, with their challenges, are such stressors. Norbeck and Tilden (1983) identified pregnancy as a maturational crisis or a time when additional support is necessary for successful crisis resolution. Themes of physical adjustment, initial insecurities, lack of support networks, and loss of former identity, were found to be coping resources needed by these mother's during the postpartum period (Nicolson, 1990). The normative stressors of pregnancy and motherhood, including loss of time and sleep, change in appetite and body image, and new identity realities and role development engage the mother to seek additional social support resource. As the rapid changes accelerate her life, the new mother looks for aid, affirmation, and affect (Kahn, 1979) from those closest to her. A question then remains, will a woman who loses social support through loss of a member of her network during pregnancy or postpartum be at higher risk 4 for developing symptoms of depression at this crucial and transitional time. Statement of the Problem Loss of a significant person in life can be a difficult adjustment. During pregnancy or the postpartum.period, loss complicates the physical and emotional changes new mothers' experience. A loss that is recognized as perceived change in support during pregnancy or in the period immediately after birth, may adversely affect the mother, given social support and its association with health and well—being (Aaronson, 1989). Awareness of a loss in the social support network may be so overwhelming to a mother, due to its valuation, she may be unable to normalize her feelings of the loss, potentially impacting her progress through the responsibilities and role acceptance the birth brings (Rubin, 1984). As her external awareness diminishes and she focuses more internally to grieve the loss, the mother may be unable to institute coping mechanisms and strategies to decrease the trauma and pain the loss has produced. This, compounded by psychological and physiological changes of the pregnancy and birth, may likewise, place the mother at an emotionally unstable point where she is unable to progress through the normal stages of the grieving process and thus, be unable to resolve the loss emotionally. The failure of 5 grief to resolve in itself keeps energy bound to the past and to the loss (Schneider, 1984). Because losses vary in terms of how significant they are, no one can determine the significance of a loss to the mother. The loss of a significant other, who would have met many needs, is a major loss in the support network. All losses threaten a way of life and are compounded by the importance and closeness of the relationship which no longer exists. These changes may be beyond the mother's ability to cope (Schneider, 1984). Loss challenges the mother's internal and external resources (Galbreath, 1990) in as much as the support network has been intentionally selected for the support resource each member provides the mother (Kahn & Antonucci, 1981). Thus, loss diminishes the resource the mother has worked to establish, even if the relationship is one of enabling and encouraging of high risk behaviors. If the mother values the relationship, the loss still diminishes a perception of positive support resource. If a loss is experienced, additional resources may be provided to the mother by the membership of the network. However, the resource provided may be in terms of functional support rather than in terms of emotional. It is the pregnant woman who defines expectations of the type of resource each individual provides to her. Emotional investment ties members to one another on an altruistic 6 level, with sensitivity to the other's needs. Individuals develop emotional relationships with others that preclude immediate emotional replacement by any other individual if the relationship is lost (Schneider, 1984). The mother, finding aspects of defined network support she perceives as important or necessary to be lacking, due to loss in the network, may be unable to cope or adjust to this circumstance. Material aspects of the support resource may be replaced by others in the support network, but if the emotional aspects of aid, affirmation and affect are missing through the mother's perceptions, the buffering of stressors may not be available to the her. Feelings of lack of control and inadequate emotional support, as perceived by the mother could potentially impact the outcome of pregnancy and birth (role acceptance) (Rubin, 1984). For those mothers experiencing a loss during pregnancy or immediately postpartum, it is important to examine any potential association existing between the loss and increased depressive symptoms in the postpartum period. A mother's ability to cope with loss may be key in establishing appropriate behaviors in the postpartum period after loss is experienced. Research Question The research question in this study was: Is there a difference in postpartum depressive symptomatology among 7 women who experience loss of a husband or partner during pregnancy and/or postpartum; those losing a parent, another relative, friend or other member of their social support network; and those who do not experience loss, after adjusting for prenatal depressive symptomatology? Purpose of the Study In the literature, little has been found regarding loss of a support member during pregnancy or the postpartum period and risk for depression. However, social support has been well researched as a factor in prevention of depression in postpartum (Cutrona & Russell, 1989; Nicholson, 1990) and has been cited by many researchers as a direct link to the risk of depression (Affonso, Lovett, Paul, Arizmendi, Nussbaum, Newman, & Johnson, 1991; Cutrona & Russell, 1989; O'Hara, Neunaber & Zekoski, 1984; Milgrom, 1994; Nicolson, 1990; Norbeck & Tilden, 1983). The relationship of a spouse or significant other has been cited to be of importance in times of stress. A close, confiding relationship with another person, usually a significant other, has been demonstrated to protect against distress during pregnancy and the postpartum period (Affonso et a1., 1991; Brown, 1986). Therefore, the focus of this study was particularly narrow to evaluate the loss of membership in a woman's support network, defined in terms of support resource lost. If factors supporting the research question were to be found 8 significant, there would be reason to institute proactive measures during prenatal visits to aid in prevention of depressive symptomatology. Because depression and its symptomatology impact not only the individual, but also the family and society, it has major financial significance. For the postpartum family, depression affects all family members. Productive work loss of the mother and those assuming her role responsibilities, expense of treatment for the depression, and out of family help for maintenance, are but a few of the financial concerns the family must face. The expense of depression on the family involves not only the resource issues, but those of risk for dysfunction. When the mother is unable to undertake her maternal role, others must assume her responsibilities. Stress is created and affects each family member's coping strategies. Maternal depression has been correlated significantly with physical abuse of children, disturbed mother-child relationships, childhood behavioral disorders, accidental injury to children and language delays (Griepsma, Marcollo, Casey, Cherry, Vary, & Walton, 1994). Families may express c0ping through anger or withdrawal from each other. Changes in relationship with partners may be encountered due to decrease in communication, the tendency of depressed women to withdraw, and the diminishing of intimacy (Martell, 1990a). Depressed mothers have been 9 found to have different styles of interacting with their infants than do nondepressed mothers, placing the child at risk for attachment issues and behavioral problems (Affonso & Domino, 1984; Cutrona & Troutman, 1986). Mother-infant bonding, the emotional and physical well-being of the baby and older children, and the marriage itself are placed in jeopardy. According to the U.S. Department of Health and Human Services (1993), one in eight individuals may require treatment for depression in their lifetime. This is over six million Americans or about 15 % of the population. Direct, and indirect costs from loss of productivity due to depression accounts for approximately $16 billion dollars per year in health care costs. In the primary care setting, depression is the seventh most common outpatient diagnosis (Parchman, 1993). The postpartum period is repeatedly cited as a risk factor for depression (Depression Guideline Panel, 1993; DSM IV, 1994; Kumar, 1990; Parchman, 1993). With the growing concerns regarding health care costs and the lack of definitive information regarding causation of depression (Beck, 1993), studies exploring predictors will increase ability to address prevention in postpartum women. Decreasing depression and depressive symptomatology by recognizing risk factors predisposing mothers to depression in the postpartum will potentially impact rates, and in turn, decrease health care costs for the nation. 10 Because depression in the postpartum period has become an ever increasing concern for health care providers, there is a need to examine potential contributors. With an incidence of postpartum depression of 10 to 15 %, (Depression Guideline Panel, 1993), there is significant need for the Advanced Practice Nurse (APN) to determine factors which may help identify women who are at-risk for depressive symptomatology. There is a need to investigate loss and the relationship of the loss within a woman's support network, and determine any psychological impact and potential problems in the postpartum period this loss could bring. Impact on the family, relationship between infant and mother, and the financial aspects of depression are but a few of the reasons to examine the factors of loss during and after pregnancy. Significant findings will benefit health care providers who may take a proactive role throughout the prenatal period in reducing depressive symptomatology in mothers experiencing loss. Conceptual Definitions Social support network, loss in the social support network, and postpartum depression were the key concepts of this study. Their relationship within the research question are explained in this section. Sooial Support Network The people with whom we surround ourselves, are the group of individuals with whom we interact during the 11 special times in life, and for everyday support and sharing. For each individual, this group or network takes on a unique dimension based on perceived need of the network's originator and the resources brought to the network by the membership, as perceived by the mother. The relationship between the mother and the membership of the network is one of shared resources. Development and maintenance of the network is the life-long task of the originator. The constant dynamism of the network matches an individual's needs through life's path. Perceived resources that are needed match the life events the individual is experiencing at any given time. This is the basis of the social support network. May (1992) conceptualized social support network as those people important to an individual with their function being that of providing social support. Mercer and Ferketich (1988) defined the support network as "connections that people have with others in their environment" (p. 27), a type of social embeddedness. Kahn and Antonucci (1981) conceptualized the support network as the set of persons who are related to one another by giving and receiving support. Further, the network is defined as having the following three characteristics: size, source of support, and duration of the support relationship. Within this definition of the support network, is the concept of resource provided or functional aspect of social support. Norbeck, Lindsey, and 12 Carrieri (1981) established their definition of personal support network based on works of Kahn (1979) for the Norbeck Social Support Questionnaire, as "each significant person in your life...all the persons who provide personal support for you or who are important to you now." (p. 265). In this study, it was the property of source of support, that is, relationship to the mother, that was a focus. Husbands, significant others, parents, family members and friends are the most common relationships of which a network is composed (Collins et al., 1993; May, 1992; Mercer & Ferketich, 1988; Norbeck & Anderson, 1989). These and other authors (Mercer & Ferketich, 1988; Norbeck & Anderson, 1989; Norbeck & Tilden, 1983) have broadened the definition of the support network to include work and school associates, neighbors, health care providers and church officials. The social support network provides the resource of social support to the individual. Elements of support are the underpinnings of interpersonal transactions between a social network of people. According to Kahn's (1979) conceptualization, the support resources of aid, affirmation and affect are provided by means of those individuals closest to a person, that person's social support network or "convoy". These are the people in an individual's life that give and receive support. Integrated with this concept, is one of change and movement along an individual's lifespan l3 and the dynamism of the support network which is moving with that individual (Reece, 1993). A strong interactive social support network has long been associated with health and well-being, emotionally, physically and psychologically. In general, support resource has direct, indirect, and interactive effects on physical and mental health, enhances health outcomes, and reduces mortality and morbidity (Stewart, 1993). It has been found that the support network acts protectively against negative life events, counterbalancing the effects of stress (Thoits, 1984). The perceived network support is the cognitive appraisal of the resource available to the individual from significant others (Turner, Grindstaff, & Phillips, 1990). Polomeno (1996) states, "this type of support reflects the caring that is available and the sense of interconnectedness and belongingness with significant others", with significant others referring to those individuals identified as important to the mother. As within any life circumstance, the position of the individual within the boundaries of the support network and their importance to the event is based on their contribution to the event and the relationship of each individual to the mother. It would generally appear that significance or importance/closeness, as perceived by the mother, would normally be attributed to the father/partner or, if not available for support to the l4 mother, to a parent or other family member (Chalmers & Meyer, 1994; Lederman, 1984; Westbrook, 1978; Zachariah, 1994). The importance of the relationship within a network that the husband/partner has as a social support resource, is recognized by Collins et a1. (1993) as they defined composition of the network resource in terms of living with the baby's father. Zachariah (1994) found social support by a partner and a woman's mother to assume more importance to a women during pregnancy compared to other sources of social support. A woman's partner or parent, usually the mother, has been found to be significant and have the most positive impact on a mother's support demands during pregnancy and childbirth (Martell, 1990b; Nichols, 1993; Zachariah, 1994). The attachments of mother—daughter and husband-wife were found to be significant predictors of psychological well-being and positive social support perceptions in a study done by Zachariah (1994). This study confirmed previous work on psychological well-being of expectant mothers and their attachment to their own mothers (Lederman, 1984) and to a husband/significant other (Westbrook, 1978). Chalmers and Meyer (1994) found that companionship for women during pregnancy and their transition to motherhood is important for psychological adjustment. Friends, doctors, other family and childbirth educators were found to be good 15 providers of support, but not as excellent as a husband or mother (Chalmers & Meyer, 1994). While there is no research that has specifically examined loss in support resource in any of these support providers and the impact on the mother's well-being, implications of the Chalmers and Meyer's study make it plausible to consider emotional dependence on a partner or parent to have higher significance in a mother's well-being; with loss of that support having a greater impact upon the mother. It is the mother's perception of who is included and excluded from the boundaries she establishes for her support system. According to Boss (1988), this is key to a person's management of stress and coping with a given situation. When lack of control, regarding these boundaries, ensues during the mother's vulnerable period ("taking-in", Rubin, 1984) after birth, there is an interplay between all of these psychosocial parameters. If the relationship with the person who is identified as no longer available or part of the support system is perceived by the mother as strong, the deficit in the network may be operationalized by the mother as hopelessness and helplessness. For purposes of this study, the social support network was defined as two or more people, one of which was a partner or parent, who were important to the mother (May, 1992), related to her through giving and receiving support (Kahn & Antonucci, 1981), and identified their membership by 16 a sense of interconnectedness and belongingness (Polomeno, 1996), based on relational intimacy and dependency. The person or persons providing support to the mother was considered important and significant in her perception, and necessary to her network. L ' i r w r It was loss of a network member upon which this study was focused. Loss in the network was defined within the mother's perception and the value or importance of the support resource the lost member represented to her. The social support resource the person provided to the mother represented the valuation the mother placed on the person in her network that was lost to her. Loss of the network member during the pregnancy or immediate postpartum period could be due to moving, a job change, divorce or separation, death or some other reason (Norbeck & Tilden, 1983). We We Recognition of depression is based on symptoms. Dejection, sadness, hopelessness, loss of interest in pleasurable activities, fatigue, indecisiveness and sleep disturbances (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; DSM-IV, 1994) are just a few of the descriptors used when characterizing depression. Symptomatology or change from normal function may be identified as a singular descriptor or a cluster of signs or indications deviating from normal. 17 The gravity of an episode of depression grows proportionally with the duration and number of symptoms manifested. Because depressive symptoms are manifestations of physiological and psychological difficulties experienced by an individual, they are globally attributed to many types of depression and help define depressive states. The commonalities among all types of depression and their symptomatology will better be explained by an examination of clinical depression. An understanding of the criteria with which clinical depression is diagnosed will aid in the understanding of postpartum depressive symptoms in this study. Depression is one of the most common and distressing human experiences. Depression does not discriminate. Social class, age, gender and ethnicity have little to do with those afflicted. According to the DSM-IV (1994), symptoms of depression cause clinically significant distress or impairment in social, occupational or other areas of functioning and are not due to a physiological effect, i.e., drug use, a medical condition, or bereavement. For a diagnosis of depression, five or more of the symptoms must be present during the same two week period, and signify a change from previous functioning. Within the diagnosis, one of the symptoms present must either be depressed mood, or loss of interest or pleasure (from DSM-IV, 1994). 18 The diagnosis of clinical depression, as defined in the DMS-IV criteria, is based on the following, and experienced nearly every day: 1. depressed mood most of the day. 2. markedly diminished interest or pleasure in activities of daily living. 3. significant weight loss (not dieting) or gain, manifested in decrease or increase of appetite. 4. insomnia or hypersomnia. 5. psychomotor agitation or retardation. 6. fatigue or loss of energy. 7. feelings of worthlessness or excessive or inappropriate guilt, not merely self-reproach. 8. diminished ability to think or concentrate, or indecisiveness. 9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or specific plan (p. 327). M r m n f D iv m Many authors have measured aspects of depression and its symptomatology. Beck et a1. (1961) designed an instrument, the Beck Depression Inventory (BDI) to establish the existence and severity of depression, focusing on cognitive and affective dimensions. Symptoms and attitudes measured include: sadness, pessimism/discouragement, sense 19 of failure, guilt, expectation of punishment, self-dislike, self-accusation, suicidal ideation, crying, social withdrawal, indecisiveness, body image distortion, work retardation, insomnia, fatigability, anorexia, weight loss, somatic preoccupation and loss of libido. Radloff (1977) designed the Center for Epidemiologic Depression Scale (CES-D) to measure cognitive, affective and behavioral symptoms and the frequency of occurrence. The scale is a measurement of the following components: depressed mood/affect, feelings of guilt and worthlessness, somatization, retarded activity, loss of appetite, interpersonal measures, and sleep disturbance. These scales which are two of the more frequently utilized instruments, were developed for measurement of depression in the general population. The CES-D and BDI provide the researcher with a comprehensive picture of the symptomatology with risk for depression. Although the descriptor wording is not exact between the two instruments, general topics of: affect, behavior, and cognition are addressed and measurable, producing like symptom recognition. The Edinburgh Postnatal Depression Scale (EPDS) designed by Cox, Holden, and Sagovsky (1987) is used to detect depression in the postpartum period. The instrument measures feelings of being panicky or worried, lack of humor, sleep disorders, feelings of being miserable, guilt, 20 and self harm. This instrument (EPDS) appears to lack the comprehensiveness that the generalized instruments possess. Recurrent themes noted in the three instruments, which are representative of the authors' concepts of depression are, sleep disturbance, guilt, worry/anxiety and suicidal ideation. With this interrelating symptomatology, coupled with the time interval of "within the last week" common to all three instruments, a case can be made that symptomatology as delineated by each instrument can define risk for multiple types of depressive states, i.e., postpartum depression, clinical depression, within a constellation of symptoms. However, these instruments are used as guides for the clinician in providing a measure of number and frequency of symptoms, and indicating need for further evaluation. 9-. . ‘ ' ' o '0. 0o._ P‘cr‘ V 4m. 01. 01-5 Historically, awareness of emotional problems following childbirth has been found to be recorded as early as the fourth century BC by Hippocrates (Nalepka & Coblentz, 1995). One of the most profound, yet unexplainable phenomenon for some women in the postpartum is that of depression. It robs those so distressed of the joy and happiness a new baby brings to a mother. With signs of clinical depression and disorders of depression in the postpartum period having few differentiating characteristics, timing of depressive 21 episode and circumstances surrounding the episode, i.e., delivery of a newborn, are the basic distinguishing characteristics used to differentiate between depressive incidents. The DSM IV (1994) recognizes Depression with a Postpartum Onset differing only in fluctuation of course and mood lability from those depressive episodes not associated with childbearing. Guilt is another distinguishing factor attributed to depression in the postpartum period (Beck, 1992). Many mothers feel guilt with regard to depressive feelings during the time when happiness is the expectation. Because of this factor, these mothers are reluctant to openly discuss their feelings, and treatment is postponed or never received, potentially escalating the intensity of the depression and possibly the duration. One of the most likely times for a woman to present with depressive symptomatology is during the childbearing years. Events such as menstruation, childbirth, illness or death of a loved one are factors that may precipitate depressive symptoms (Pariser, 1993). The term "postpartum depression" is often used to describe three distinctive types of postpartum depression (PPD) which vary greatly in severity and duration, and with boundaries between them not always clear. The first is a transient depression and the mildest form, known as "baby blues". It ordinarily occurs in the first days of postpartum, and lasts a few days to a few 22 weeks and affects 50 to 80% of new mothers (Cox, 1989). It is characterized by tearfulness for no apparent reason, anxiety, restlessness, irritability, oversensitivity and mood swings. Possible causes for this depressive symptomatology are lack of sleep, major life changes, sudden drop in progesterone and estrogen, increase in demands the mother faces, and readjustment psychologically of usual and consistent routines. A second type of PPD, postpartum psychosis, the most severe type, occurs in 0.5-2 per thousand women who may experience delusions, hallucinations and impaired concepts of reality. The woman may or may not have had chronic depression in the past. Symptoms generally begin about three days after childbirth and include fatigue, tearfulness and mood lability, much like the milder disorders. Confusion, agitation, disorientation, suspicion and obsessive concern about the baby begin soon after the mother is discharged. Incidence is independent of social, cultural, nutritional and medical factors (Kumar, 1990). Hospitalization, medication and therapy are usually the regimen for those with this type of depression. It may last a few months to years. The third type of depression is Postpartum Depression (PPD) which generally refers to the onset of depressive symptoms experienced in the period immediately after childbirth. This condition, which may develop any time in 23 the year after the birth of a child, occurs in 4 to 15% of new mothers. The usual time frame for onset is within the first six weeks postpartum, and may last for more than a year (Driscoll, 1990). Atypical anxiety, fatigue, and phobias are prominent, as are the typical depressive symptoms of low mood, lack of interest or pleasure, guilt, lack of appetite, and sleep disturbance. Recovery from PPD is usually within a year's time, although some mothers may Continue to display symptoms such as irritability, fatigue, depression, or disinterest in activities. Recurrence risk has been reported to be 30 to 50% (Knops, 1993). In a qualitative study of Postpartum Depression (PPD), Beck (1992) interviewed seven women who had suffered from PPD and found the themes of: unbearable loneliness, loss of previous interests and goals, inability to concentrate or make decisions, uncontrollable anxiety attacks, insecurity, suicidal ideation, and obsessive guilt. These women found their lives compromised by this phenomenon to the extent they were unable to function in their previous capacity. These findings reflected those of Radloff's (1977), when designing the CES-D. The clinical signs and symptoms of postpartum depression are comparable to non-postpartum depression such as feelings of inadequacy, anxiety, despair, lack of energy, loss of interest in sexual activities and compulsive 24 thoughts. The content of the mother's depressive thoughts, however, are concentrated on her sense of inability to love or to love adequately, and on her ambivalence towards the infant (Chalmers & Chalmers, 1986). Depressive symptomatology following childbirth may manifest in various forms. The recurrent themes and risk factors found in the literature and that of the DSM IV appear to be lack of control, labile hormonal changes, role change and acceptance, anxiety, loss of interest in activities or pleasures, fatigue, guilt, inability to make decisions, decreased self—worth, and despondency. For purposes of this study, postpartum depressive symptomatology was defined as a cluster of symptoms based on loss in various areas of physical, psychological and social functioning (Beck, 1993; Chalmers & Chalmers, 1986; DSM-IV, 1994), and which are present at varying intensities during a week. Presence of these symptoms may be indicative of need for further investigation for clinical or postpartum depression if frequent or severe enough. These symptoms are: irritability, crying spells, depressed mood, feelings of guilt and worthlessness, feelings of fear, helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep and attention disturbance (Radloff, 1977). Conceptual Framework Roy's (1984) Theory of the Person as an Adaptative 25 System was selected as the framework to guide in the explanation of the relation between the variables of loss within the social support network, and depressive symptomatology in the postpartum period. The mother's role, the stressor of loss, her relationship to the internal and external environment, and adaptation is described within the study model. The essence of the Roy (1984) model is based on the adaptive behaviors of a person adjusting to environmental stressors, both internal and external. Environment is all conditions, circumstances and influences surrounding and affecting the development and behavior of a person. Adaptation is a positive response to internal or external stimuli using bio-psycho-social and spiritual mechanisms to promote personal integrity. A person's ability to respond positively or adapt is based on the degree or extent of change experienced and the ability of the person coping with the change (Roy). A person's adaptation level or ability to cope is determined by the effect of three classes of environmental stimuli: focal, contextual, and residual. Focal stimuli is the degree of change immediately confronting the person, in simpler terms, the environmental change to which the person must adapt (Roy, 1984). In terms of this study (See Figure 1), the focal stimuli is loss in the support network, represented by the rectangle on the left of the model, Swo—oueaoagw 033.29% was #836 Z tomasm 38m 9652: a E .8982: Luau—mime a mo 32 ofi 52,33 minnows—8 05 @365 889$ “Stage. 5 ma newton mo >823. mamom mo 593633.. A warm Scam Seamssssaoo 22532 Co ocoN 3653 >mo.3mESnE>w 0339.30 26 226.33. to 83 553 >mo_oquounE>m 633230 oz 55230225 8:251 Sam 58:00.23 $062295 moves. ( Passages 5522 \\\II//// \ Loamcmoo A\§/ A ¢ \ \ seaweed 4 I l/ Cougamom sensuous .352: {9302 .350 355.. < moo... x3232 toqnzm Enom :35 .86". a EoE:8_>cm_ 27 compounded by the role change demands of pregnancy and new motherhood within the mother's environment. Contextual stimuli are all other environmental stimuli present that influence the mother's adaptive response. The contextual stimuli are represented in the model by the large, surrounding rectangle and contain the support network, the memberships' tangible and emotional support, and the changes evolving from the pregnancy with respect to role, body image, responsibility and relationships. The residual stimuli are those beliefs, attitudes, traits and experiences that have an effect on the situation, as something previously learned that affects current response to focal stimuli; the mother's perception of support provided by each member rather than the actual behaviors, previous experiences with loss, and significance of the lost member. Residual stimuli are represented within the mother's environment. These stimuli are bits of information or inputs and are considered stressors, provoking the adaptive mechanisms of the mother to function (Roy, 1984). The mother is represented by the central oval of the model and contained within are her perceptions of support. Constant change and adaptation transpire during pregnancy for all women. This is the environment the model represents. There are physiological and emotional changes happening from the moment the pregnancy is recognized (Rubin, 1984). According to the Mutation (ROY. 28 1984), the impact of these changes may be modified by the effect of the social support given by the members of the support network (contextual stimuli) only if the mother recognizes the support by means of residual stimuli (Roy). Even if the behaviors of others indicate the presence of support, if the mother does not perceive support to be available, it cannot be used. Adaptation occurs only when the total stimuli (focal, contextual and residual) affecting the person fall within the zone of adaptation or the limits of the person's adaptive capacity (Galbreath, 1990). Within Roy's framework, the mother is an adaptive holistic system having a set of inputs, control and feedback processes and outputs, represented by the feedback loop. In other words, a living adaptive system in constant dynamic interaction with the environment, maintaining the integrity of one's being by adapting to internal and external changes. The adaptive system of the mother has input coming from the external environment (social support) as well as input from within, which are her perceptions (residual stimuli). It is these units of information, matter, or energy from the environment or from within that elicits a response, either adaptation or ineffective to the stressor (loss). The level of stimuli and the mother's level of adaptation act as the boundaries from which she is able to respond or output behaviors. Behaviors can be internal or external. Adaptive behaviors are those responses that promote integrity of the 29 person. Ineffective responses promote maladaptive behavior and do not promote integrity (depressive symptomatology). Each person's adaptation level is constantly changing through an internal and external feedback loop and is influenced by the coping mechanisms of that person (Roy, 1984). The adaptation level represents the range of stimuli that the person can tolerate and maintain an adaptive response. The coping mechanisms that are used by the person to achieve adaptation to stimuli are the regulator and the cognator, represented within the central oval by two overlapping circles. Within the overlapping circles lies the mother's perceptions of support. The regulator and cognator are subsystems of the person, and working through the four adaptive bio-psycho- social modes, they represent the mother's perceptions of any given circumstance. The regulator mechanism is the basic or autonomic response of a person such as a reflex action or an antibody/antigen response or the physiologic responses such as sleep disturbances and change of appetite. The cognator mechanism is related to higher brain functions such as perception, judgement and emotion. It acts consciously by thought and decision, such as the response made to loss in the support network and the importance placed upon that member as a resource. In maintaining the integrity of the person, the regulator and cognator work together through the adaptive 30 bio-psycho-social modes, represented in the rectangle to the right of the oval. The physiological, self-concept, role function and interdependency adaptive modes are based on the mother's need for physiological, psychic, and social integrity (Roy, 1984). If integrity is threatened by loss, coping ability decreases. If regulator and cognator activity is manifested through c0ping behavior, the adaptation level of the mother is broadened and the range of stimuli to which she is able to respond positively is increased. If the cognator is unable to respond effectively to role expectations of postpartum, due to loss of a specific network member, in other words, "shuts down", the adaptation level may be unexpectedly narrow and preclude role acceptance, or motherhood, itself. Maladaptive behaviors expressed by the mother may be exhibited in terms of depressive symptomatology. Since adaptation is facilitated by the use of both the regulator and cognator coping mechanisms (Roy, 1984), lack of cognator mechanisms could potentially lead to a decrease in regulator ability, i.e., the physical symptoms of depression: sleeplessness, changes in appetite or psychomotor activity, decrease in libido (Beck, 1992; DSM- IV, 1994). When a specific and valued member of the network is lost to the mother, there is a stimulus or a stressor experienced, represented by the first arrow within the 31 feedback loop. The support resource may be functional, emotional, or both that the lost member provided (or received) from the mother. If the focal stimuli/stressor of loss in the support network impacts the contextual and residual stimuli of role change and compounds the already unstable and changing environment in which the mother must function due to her perception of new roles and relationships (residual stimuli), the mother's adaptation level or coping mechanism may be inadequate for the degree of change the mother is facing. Thus, the adaptation level narrows and the level of stimuli that is tolerated decreases due to the loss of the member, significance placed on the member, and the loss of contextual stimuli provided by that member. Loss of a husband or partner, or some other member of the support network at this time, if perceived (residual stimuli) by the mother as a significant and valued support resource, may decrease coping and narrow the zone of adaptation beyond the mother's ability to adapt to the stressor. If the resources of the members within the network are unable to provide additional support (contextual stimuli) to maintain the resource level and increase the adaptation level of the mother, there is the potential for an ineffective response due to a stimulus beyond the mother's c0ping ability and depressive symptomolgy may occur. Inability to adapt to the focal stimulus of the loss may potentially lead to maladaptive behaviors by the mother. 32 Therefore, when the total stimuli fall outside the mother's zone of adaptation, ineffective behavior or responses occur. A person's ability to cope varies with the state of the person at different times (feedback loop). The person who has suffered a major trauma (loss of a person providing a close and confiding relationship, i.e., parent, partner, relative, or friend) has a narrowed zone of adaptation. Therefore, loss may subject a mother to greater risk for the ineffective response of depressive symptomatology than those women who have experienced no such loss. Review of the Literature In reviewing the current literature on social support and its implications with regard to postpartum depression, depressive symptomatology and risk factors, no research has directly evaluated loss in the support network and its relationship to risk of depressive symptomatology. Functional support has been the focus of the majority of the studies looking at the connection between support networks and risk of depression (Collins et al., 1993; Logsdon et al., 1994; Norbeck & Anderson, 1989; Norbeck et al., 1981; Turner et al., 1990). In the current literature, it was found that no single causative factor can be determined to contribute to the problem of depression in the postpartum period. Studies defining the etiology of postpartum depression cite biological, psychological and sociological factors during 33 pregnancy and delivery as possible determinants (Adcock, 1993; Arizmendi & Affonso, 1984; Chen, 1995; Mills, Finchilescu, & Lea, 1995; Thurtle, 1995). There have been a number of studies done on the subject of prenatal factors that are considered predictors of depressive symptomatology in the postpartum (Affonso et al., 1991; Affonso, 1987; Mercer & Ferketich, 1988; Tilden, 1983), on adaptation to postpartum stressors (Affonso, 1987) and on treatment regimens (Clement, 1995; Gerrard, Holden, Elliot, McKenzie, McKenzie, & Cox, 1993; Jermain, 1992; Nalepka & Coblentz, 1995; Vines & Williams-Burgess, 1994). In a study done by McIntosh (1993), there was found to be a significant association between symptoms of depression and the amount of support obtained from a partner. Marital difficulties have been significantly associated with depression in postpartum (Watson, Elliot, Rugg, & Brough, 1984) and perceived emotional support that has deteriorated in a marital relationship. Loss of the support, and feeling unloved by a partner was found to have a highly significant correlation with postpartum depression (Arizmendi & Affonso, 1984; Boyer, 1990). Distress experienced during the pregnancy from inadequate support, affection and security through loss or perceived loss of a member of the network, has been posited to potentially evolve into negative feelings regarding self and fulfillment of the maternal role (Cronenwett, 1985). Cronenwett found the social support 34 network providing support resources for the mother to be a strong predictor of parental role satisfaction and positive psychological effects on pregnancy outcome. In a meta-analysis of predictors of PPD, Beck (1996) analyzed 44 studies addressing predictors of postpartum depression and the magnitude of their relationship as predictors. These predictors focus primarily on determinant identification in the prenatal period. Prenatal social support was shown to have a moderate effect as a predictor of PPD . In a study by Polomeno (1996), social support was found to influence individuals to adhere to healthy routines. It was also found to mitigate the effects of stress as it moderates the impact, and facilitates the individual's c0ping. Social support has been found to assist in the appraisal of potentially threatening situations or problems, and could, through its buffering affect, prevent a person from going into crisis. Affonso et a1. (1991) completed a prospective study analyzing the predictive value of four factors: marital relationship, stress, social support and cognitive influences as predictors of depressive symptomatology in postpartum. In this study, these psychosocial factors, were found to be predictive of severity of depressive symptoms in both pregnancy and postpartum. Mercer and Ferketich (1988) also found a significant relationship between social support 35 and stress as predictors of depression during pregnancy. Other studies have found a significant relationship between social support and postpartum depression (Collins et al., 1993; Logsdon et al., 1994). These studies corroborated previous research by O'Hara (1986) and O'Hara et al. (1984) that a variety of prenatal factors contribute to the manifestation of depression in postpartum. Seguin, Potvin, St.Denis and Loiselle (1995) state there is a direct link between social support and mental health because the unavailability of social support when needed is strongly associated with the depressive symptomatology of pregnant women. Hall, Gurley, Sachs and Kryscio (1991) have associated higher depressive symptoms with fewer social support resources. Logsdon et al. (1994) have found that failure to receive anticipated support resources may lead to negative consequences or depressive risk factors in the postpartum period. Supportive relationships have been found to enhance feelings of well being and personal control (Norbeck & Anderson, 1989). Other studies corroborated that poorer marital relationships and less social support from family and friends led to increased depressive symptomatology in pregnancy (O'Hara, 1986; Robinson, Olmstead, & Garner, 1989; Whiffen, 1988). Zachariah (1994) has attributed the importance women place on partners and their own mothers in positive birth 36 experiences and role acceptance of motherhood. Yet, specific composition of networks and membership significance within the network (Tarkka & Paunonen, 1996) have been poorly represented in the literature. Studies measuring the incidence and degree of depression are prevalent in the literature (Barnet, Joffe, Duggan, Wilson, & Repke, 1996; Gotlib, Whiffen, Mount, Milne, & Cordy, 1989; Saks, Frank, Lowe, Berman, Naftolin, & Cohen, 1985; Zelkowitz & Milet, 1995; Ugarriza, 1995; Viinamaki, Rastas, Tukeva, Kuha, Niskanen & Saarikoski, 1994) and have identified that up to 75% of postpartum women will be affected by one of three types of postpartum depression: blues, psychosis, or non psychotic depression. Studies developing screening instruments to help determine mothers with depressive symptomatology and potential for depression are becoming more prevalent (Affonso, Lovett, Paul, & Sheptak, 1990; Beck, 1995; Ugarriza, 1995). Many studies have attempted to explain the vulnerability women experience to depression during the period following childbirth. It has been universally accepted in both the medical/clinical and the social science arenas that depression in the postpartum is a very real problem with unknown etiology. The response to physiological and/or social-psychological changes associated with pregnancy and birth have been cited as reasons, in attempts to explain the phenomenon of the range of emotional 37 reactions, generally characterized as depressive, in the postpartum period (Frate, Cowen, Rutledge, & Glasser, 1979; Hayworth et al., 1980; Unterman, Posner, & Williams, 1990). Loss was identified by Driscoll (1990) as a recurrent theme in postpartum depressive symptomatology, with the mother experiencing loss in relationships, self—esteem, energy and life—style. Driscoll implies that once loss is recognized by the mother, she will experience a grieving process which will then allow coping mechanisms to begin and she will initiate the process of acceptance of the new postpartum role. With this in mind, determination of factors placing prenatal and postpartum women at risk for depression, and appropriate steps in resolution of these risk factors should be further studied. Corroboration of existing literature and exploration of other potentially predictive factors have as yet just touched the surface of this problem. 2 . . E l 1' It is apparent that the concept of loss in the network with regard to source of support and pregnancy is a needed area of research and a limiting factor in the literature concerning PPD. However, the concept of social support and social support network has been well documented in the current literature. Even so, social support is quantified as support given and structure of support ties (Affonso & Domino, 1984; Cronenwett, 185; Gjeringen & Chaloner, 1994; 38 O'Hara, 1986) and not in loss of support. Mercer and Ferketich (1988) measured negative life events during pregnancy as predictors of depression, yet loss of a person in a network was not specifically addressed. This and studies like this one would fill that gap. Although difficult to quantify, emotional support of the mother during pregnancy must become an evaluation standard, when studying the prenatal and immediate postpartum period. Little research has differentiated the emotional from the functional aspects of support (Cronenwett, 1985; Gjeringen & Chaloner, 1994; O'Hara, 1986). Depression is a variable that has been well addressed in the literature. Instruments such as the CES-D (Radloff, 1977), the BDI (Beck et al., 1961) and the EPDS (Cox et al., 1985) are widespread in the literature. Emotional impact of depression is prevalent in studies as analyzed by Beck (1996) in the meta—analysis of 44 studies. Research methodology is limited within the scope of the study variables. It is limited to convenience sampling, subjects with like characteristics, such as low-income or middle class, majority married, majority living together, limited sample size and lack of generalizability (Affonso, et al., 1990; Lantican & Corona, 1992; May, 1992; O'Hara et al., 1984; Seguin et al., 1995). Attrition of the sample subjects have further limited generalizability (McIntosh, 39 1993). These methodology problems have been repeated in this study. Because postpartum depression is not limited by socio- economic status, age, health or ethnicity the need to identify risk factors is considerable. There is no textbook profile that characterizes and identifies all mothers at risk, merely predictors. If reliable predictors are established through repeated validative studies, providers will have the ability to focus care during pregnancy so that potential risk can be minimized using anticipatory guidance and encouraging development of an effective support system. There is a need for further research recognizing and validating reliable predictors for risk of depression, and the establishment of screening standards for improved prevention. Studies addressing loss in a mother's social support network from the prenatal period to that period after the birth have not been found in the literature. This study has begun to address the deficiency found in the literature. Methods W This study is a secondary analysis of data collected for a larger primary study entitled, "Factors Influencing Pregnancy Outcome at the Center For Healthy Beginnings, Jackson, Michigan" by Schiffman and Omar (1994). The original study examined factors influencing adequacy of 40 prenatal care and pregnancy outcome in the low income women served by a private, not-for-profit center. Subjects were enrolled and data collected between May, 1992 and May, 1993. This secondary analysis uses a non-experimental design to examine the data pertaining to the association between loss in the social support network and depressive symptomatology in the postpartum period of low income women. The primary study, an evaluative study, included prospective survey instruments the participants were asked to complete on the first prenatal visit and one of the next two, and the postpartum visit. A chart review was done on the initial prenatal visit and after subjects attended their postpartum visit. Simple A non-probability convenience sample of 33 women from the primary study, reporting at least two persons in their support network, and who completed the Norbeck Social Support Questionnaire (NSSQ), and the Center for Epidemiologic Studies Depression Scale (CES-D) were selected. The instruments were completed at the prenatal and postpartum data collection points. The primary sample was composed of 132 women, with an average age of 23.4 years (SD = 5.58), living in Jackson county seeking prenatal care during May 1992 through May 1993. The majority were single, multiparous and of the caucasian race, and had a high school diploma or GED. 41 Almost 94% of the primary sample had either Medicaid or a Medicaid pending insurance status. Table 1 Frequency and Percent of Demographic Characteristics of Sample (n = 33) ri i n % Maternal Age 10-19 10 30.2 20-29 17 52.3 30 and above 6 17.5 Educational Level ==e2=3 .3 z 3 .335. .a s... 3 $2 0 s more on 25: an .6 on ”:2 e39. cornice .9. <2 30., >05. .02. 50> c. 30:2. 3359.: 25.. 30> on .33. >5... 3 :3 .339 z :n 33 o. 2.2. .0: 0.. 30> 350 l . BottstntuEEE l :32»... to 3.3.53 l S330... 2.5 5.3.. I 209...»: I 3.203: .005. to {03 I 35:. l «3:12 .0 C362: >55. l 3:22. .0 :32: l .33 30> 5 >30- : .302. >c2c 3 .5 3: .30> e. 32.09.: .303 2: .0 :55 30> 22. o. .5 3.30:0. 2: a5 .8» .fiowidswz . or .wsi e 01w. an. (i 4 n. .v dun-our 0<4 .Ll. <& .n darkened. ”om. .~ 91053» ..r his}: _ 2:30:33. 32::- 5 2.22 3:”. 5.3535 63:3.» 3:30:0— 2: E 3 .9530323 .5 335:. to... 3:4 .325: 3 3:3: .2; >75 3: 30> o. 2.3.095. a: 0..) .0 30> 3.. 20.33 2:022. «.552. on! «coated on. .2. 32:25 .2”: 2: en a... 50> c. c023 2.3::3: no: .r. 23... .C22215a NQQKNQ .qui at: 20 mzoskUwQCQ “a... QTWQ Math um uE 0. 932.23 .995. o: 9: 9.3 9302. 03... >3 supra... 33 Zone... .3o> .o .33... >5.- .=~.u>0 no 2:925 .220 332:3..3535... 5:22: .0 3.0333 33.15... v.3 .33.. «2.....32. llIlIIIl 3.23.: .093. .c .203 not»... uni-29. .3 22.59... >=:.~. .95.»... .c 33...: IlIIIlIIl .:o> 0. e333... been. 9. 2a 9.3 >.ouo.3 :93 3.0.. 2.022. .o .35.... a... 23%... 33... .3 mm...) .2 3) .- 02 .o . .333. 3:5 2:3 .0 .53.. ...0_.~.2_u. .3 3.3»... .953... :c. a $5.5... o. 2... :.....:c:2e. 2.2.2:... >..e .5. ..o> 2.3. ..~u> .3: u... 5.2:: 6 8 APPENDIX F Center for Epidemiologic Studies Depression Scale CES-D Scale (A) Circle the number for each statement which best describes how often you felt or behaved this way -— DURING THE PAST WEEK. Rarely or Some or I Occasionally or 3 Mat or None of Little of Moderate Amount All of the Time the Time of Time the Time (Less than . 1 Day) “'2 0m) (34 am) (>7 Days) DURlNG THE PAST WEEK: l. l was botheted by things that usually don't homer me O 1 2 3 2. I did not feel like eating: my appetite was poor 0 1 2 3 3. I felt that lcould not shake offthe blues even with the help from my family and ‘ (fiend: 0 I 2 3 4. lfeltthatfwasjtmasgoodasomer pegplp 0 1 2 3 S. I had trouble keeping my mind on what I was doing 0 1 ' 2 3 6. lfelt dept-cant 0 1 2 3 7. I felt that everything ldld was an effort 0 . 1 2 3 8. I felt hopeful about the mmw... o l 2 3 9. l thoaght my life had been a failure..- 0 1 2 3 10. I felt featful 0 1 2 3 ll. My sleep was restless o 1 2 3 12. l was happy 0 1 2 3 13. I talked less than usual 0 I 2 3 14. l felt lonely o I 2 3 l5. People wen unfriendly--.......... 0 1 2 3 l6. [enjoyed life 0 1 2 3 l7. l had etyin. spell! o 1 2 3 I8. I felt sad 0 1 2 3 t felt that people disliked me.......... o l 2 3 20. I could noc get 'going' .................... .. 0 1 2 3 LIST OF REFERENCES 69 References Aaronson, L.S. (1989). Perceived and received support: Effects on health behavior during pregnancy. Enrsing EfifififiuzflLn;l&(l), 4-9. 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