Screening women for distress during pregnancy: the impact of including 'Possibly' as a response option

OBJECTIVES

To investigate the impact of including the response option of 'Possibly' in the Distress question on the Matthey Generic Mood Questionnaire (MGMQ) during antenatal emotional health screening in English-speaking women.

BACKGROUND

Some distress screening questions only allow respondents to choose between 'Yes' or 'No' to the presence of distress. The MGMQ, however, allows respondents to chose between 'Yes', 'Possibly', or 'No', which may be preferable if a participant is reluctant to state she definitely feels distressed.

METHOD

In Study 1, women undergoing routine antenatal psychosocial screening were allocated to either completing the MGMQ Distress question with the usual three-option response format of 'Yes, Possibly, No' (N = 960), or just a 'Yes, No' response format (N = 771). The proportion of responses were compared in each group, as were the proportion then screening positive on the MGMQ's Bother question. In Study 2, women (N = 113) attending routine antenatal clinic appointments were asked about their preference between these response formats.

RESULTS

Including 'Possibly' resulted in only a slight increase in the proportion giving a positive response to the Distress question, and then also screening positive on the Bother question. In Study 2, a substantial majority of women (80%) preferred having 'Possibly' in the response options.

CONCLUSION

While the impact of including 'Possibly' is small, it allows for more women to communicate how they are feeling on the full MGMQ. Given the large majority of women preferring having 'Possibly' included, we believe that the Distress Question is enhanced by having this as a response option.

Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: implications for clinical and research practice

OBJECTIVES

i) To highlight the increasing use in the literature of unvalidated cut-off scores on the Edinburgh Depression Scale (EDS/EPDS), as well as different wording and formatting in the scale; ii) to investigate and discuss the possible impact of using an unvalidated cut-off score; iii) to highlight possible reasons for these 'errors'; and iv) to make recommendations to clinicians and researchers who use the EDS/EPDS.

METHOD

A convenience sample of studies that have used unvalidated cut-off scores, or different formatting, are cited as evidence that these types of 'errors' are occurring fairly frequently. Examination of previous data from one of the authors is undertaken to determine the effect of using an unvalidated cut-off score.

SUMMARY

Many studies report rates of high scorers on the EDS/EPDS using different cut-off scores to the validated ones. The effect of doing this on the overall rate can be substantial. The effect of using different formatting is not known, though excluding items from the EDS/EPDS must also make a substantial difference.

RECOMMENDATIONS

We recommend that i) the validated score of 13 or more is used when reporting on probable major depression in postnatal English-speaking women, and 15 or more when reporting on antenatal English-speaking women; ii) that the wording used is "13 or more" (or equivalent), and not other terms that may cause confusion (e.g., '>12'; 'more than 12'; '13' etc), iii) if a different cut-off score to the validated one is used, a clear explanation is given as to why this has been done; and iv) that the scale should be worded and formatted as originally described by its authors.

Acceptability of routine antenatal psychosocial assessments to women from English and non-English speaking backgrounds

The acceptability of routine psychosocial assessments to women and staff at an antenatal clinic of a public hospital in Sydney, Australia, was investigated. 104 English-speaking women had a telephone interview within a few days of the psychosocial assessment, and 65 of these women also participated in a telephone interview 5-8 weeks after the birth. 14 midwives who had administered the questions were also interviewed. These three sets of interviews indicated that the majority of women and staff considered the psychosocial questions to be appropriate and helpful. Prior to introducing a shorter version of the psychosocial assessment for all women, consultations took place with health professionals and community women from Arabic-speaking (n = 30) and Vietnamese-speaking (n = 39) backgrounds to determine the expected suitability of such questions to women from these ethnic backgrounds. The only consistent concern was that the term 'husband' should replace 'partner' when interviewing Arabic-speaking women. Telephone interviews were then conducted with a sample of Arabic-speaking (n = 48) and Vietnamese-speaking (n = 50) women within a few days after they had been to the clinic. As with the English-speaking women, most considered the questions to be appropriate and acceptable.

Routine psychosocial assessment of women in the antenatal period: frequency of risk factors and implications for clinical services

Routine psychosocial assessment was introduced at an Australian public hospital's antenatal clinic in 2001. After modification, this assessment consists of 12 questions together with the Edinburgh Depression Scale (EDS). Data are reported for responses to these questions from over 2,000 English-speaking women presenting to the clinic in a 12-month period. These 12 questions and the EDS were categorised into seven risk domains, with 12% of the women (n = 260) having three or more of these risk domains. Referral information to one of our two clinical services shows that 6.7% of women assessed in the antenatal clinic become clients having face-face counselling, and a further 7.2% have just telephone contact with this specialist perinatal mental health service. This information should prove useful for services considering implementing routine psychosocial assessments (or "screening") in the antenatal period.

The sleep and settle questionnaire for parents of infants: psychometric properties

OBJECTIVE

To determine the psychometric properties of a parent-report questionnaire (Sleep and Settle Questionnaire (SSQ)) assessing: (i) the infant's sleep and settling behaviour, and (ii) the parent's level of concern with such behaviours.

METHODOLOGY

Test-retest reliability was determined by administering the SSQ to 20 mothers on two occasions, 7-14 days apart. Validity was determined by comparing SSQ responses between mothers with 6-week-old infants who, on a semistructured questionnaire, reported no sleep or settling difficulties (n = 56-60) with those who reported they were experiencing difficulties (n = 133). Further comparison was made with a sample of mothers (n = 34-36) attending a community class on sleep and settling difficulties with infants. Sensitivity to change was determined by comparing mothers' SSQ responses at 6-weeks and 6-months postpartum.

RESULTS

The SSQ was found to have low test-retest reliability on items referring to the infants' sleep and settling behaviour, but moderate reliability for the extent that such behaviour bothered the parent. Comparison across the different samples showed good discriminant and concurrent validity.

CONCLUSIONS

Parental reports on the SSQ indicates that over a short period (1-2 weeks) the infants' sleep and settling behaviour can change considerably, but that the extent to which such behaviour bothers the parent is more stable. Good validity demonstrates the SSQ is sensitive to differing infant behaviour. It is recommended as both a clinical and research instrument, and could be used to complement assessments focusing on the parent's psychosocial adjustment in the early postpartum period.

Validation of the Edinburgh Postnatal Depression Scale for men, and comparison of item endorsement with their partners

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) has been validated and used extensively in screening for depression in new mothers, both in English speaking and non-English speaking communities. While some studies have reported the use of the EPDS with fathers, none have validated it for this group, and thus the appropriate cut-off score for screening for depression or anxiety caseness for this population is not known.

METHODS

Couples were recruited antenatally and interviewed at six weeks postpartum. EPDS scores and distress caseness (depression or anxiety disorders) for 208 fathers and 230 mothers were determined using the Diagnostic Interview Schedule.

RESULTS

Analyses of the EPDS for fathers using distress caseness (depression or anxiety disorders) as the criterion shows that a cut-off of 5/6 has optimum receiver operating characteristics. Furthermore acceptable reliability (split-half and internal consistency) and validity (concurrent) coefficients were obtained. For mothers the optimum cut-off screening value to detect distress caseness was 7/8. Item analysis revealed that fathers endorsed seven of the ten items at lower rates to mothers, with the most significant being that referring to crying.

CONCLUSIONS

The EPDS is a reliable and valid measure of mood in fathers. Screening for depression or anxiety disorders in fathers requires a two point lower cut-off than screening for depression or anxiety in mothers, and we recommend this cut-off to be 5/6.

Paternal and maternal depressed mood during the transition to parenthood

BACKGROUND

The course of postnatal depression was examined in first-time mothers and fathers with emphasis on the role of personality and parental relationships as risk factors.

METHOD

157 couples were assessed at four points: antenatally and at 6, 12 and 52 weeks postnatally. Various measures of mood and personality were administered at each of these assessment points.

RESULTS

Examination of the factors associated with depressed mood suggested that a woman's relationship with her own mother was important in the early postpartum stage, and also her level of interpersonal sensitivity and neuroticism. For the father, his relationship with either his mother or father and his level of neuroticism were associated with his mood level early on. By the end of the first year couple morbidity increased, with rates of distress being at their highest for both parents, and factors associated with depressed mood being linked to partner relationship variables, at least for mothers. At most time points, antenatal mood and partner relationship were significant predictor variables for the postnatal mood of both mothers and fathers.

LIMITATIONS

The sample had a relatively high level of education and this should be taken into account when considering the generalisation of findings to less educated populations. At the time of conducting this study, the Edinburgh Postnatal Depression Scale (EPDS) had only been validated for use in the first few months postpartum, and thus we used another scale to measure the mother's mood at the other assessment points (the Beck Depression Inventory). Current research would suggest that the EPDS is valid both antenatally and at other times in the first year postpartum.

CONCLUSION

Whilst there was some consistency for mothers and fathers in the variables that predict their postpartum adjustment, these being antenatal mood and partner relationship, there is also evidence that adjustment to parenthood was related to different variables at different times. Early adjustment was related to the couple's relationship with their own parents, as well as their own personality. Later adjustment was related to the couple's functioning and relationship.

Migration and motherhood: a response to Barclay and Kent (1998)

A recent paper by Barclay and Kent (1998) raised various issues with regards to motherhood and recent immigration. They expressed reservations with conceptualizing extreme misery in new mothers as depression, and with screening for postnatal distress in women from non-English-speaking backgrounds (NESB). They argued that a common self-report measure for postnatal distress screening, the Edinburgh Postnatal Depression Scale (EPDS), was flawed. They also argued that the concept of postnatal depression implies a medical aetiology and, thus, fails to recognise the socio-cultural aspects experienced by NESB women. We address these issues, by demonstrating that the EPDS is not flawed, and by arguing that screening for postpartum distress results in more NESB women being identified and, consequently, offered a service, than if such screening does not occur. We also disagree with the view that the term 'postnatal depression' necessarily implies any aetiology, and that work by our unit, as well as others around the world, indicates that the psychosocial and cultural aspects related to distress in new immigrant mothers is being recognised and acted upon.

Postnatal depression and social supports in Vietnamese, Arabic and Anglo-Celtic mothers

The significance of a western woman's social supports to postnatal depression is well documented. We examine which deficits in components of their social support network are associated with postnatal depression in women from a non-English-speaking background. The social support network and postnatal mood of 105 Anglo-Celtic, 113 Vietnamese and 98 Arabic women were assessed at 6 weeks postpartum. The role of social supports in determining scores on the Edinburgh Postnatal Depression Scale (EPDS) was analysed using multiple regressions. For Anglo-Celtic women, low postnatal mood was associated with perceived need for more emotional support from partners and mothers. For Vietnamese women, low postnatal mood was associated with poor quality of relationship with the partner and a perceived need for more practical help from him. For Arabic women, low postnatal mood was associated with perceived need for more emotional support from partners. We conclude that cultural factors mediate the relation between social supports and postnatal depression more likely to become clinically depressed (Lovestone and Kumar 1993) and infants may have adverse cognitive, behavioural and emotional outcomes, which can be linked to the postnatal depression (Murray and Cooper 1996).

A group programme for postnatally distressed women and their partners

A group programme for postnatally distressed women and their partners is described. The programme consists of eight sessions, including one session for the couple. The concerns of the women centre around their anxieties and feelings towards their partners, their own mothers and their infants. Psychotherapeutic and cognitive-behavioural strategies are employed to assist them in dealing with these concerns. The concerns of the men centre around their attempts to provide emotional and practical support to their partner. Invariably such support results in an increase in tension between the partners, and the programme helps the men to understand why this happens. Formal measures show a decrease in maternal distress over time and an increase in their level of self-esteem. About half of the men show elevated levels of distress.

Vietnamese and Arabic women's responses to the Diagnostic Interview Schedule (depression) and self-report questionnaires: cause for concern

OBJECTIVE

The original study aimed to determine the best cut-off scores to screen for postnatal depression on translated versions of the Edinburgh Postnatal Depression Scale (EPDS) for Vietnamese and Arabic women. This research was conducted using the depression module of the Diagnostic interview Schedule (DIS) to determine caseness. This paper reports on the suitability of this diagnostic interview as a criterion measure of depression in these women with a non-English speaking background.

METHOD

Vietnamese and Arabic women in south-west Sydney completed the EPDS and a General Health Questionnaire (GHQ-30) antenatally. At 6-8 weeks postpartum they completed an EPDS, the GHQ-30 and a Faces Scale, and were interviewed using the depression module of the DIS. Members of a small convenience sample of women were asked about the cultural appropriateness of each of the instruments.

RESULTS

Vietnamese women admitted to few depressive symptoms on the DIS, whereas they appeared more open to reporting these on the EPDS and the GHQ-30. Arabic women responded more openly to the questionnaires and the interview, although they too were reluctant to report specific symptoms on the DIS.

CONCLUSION

The usefulness of the DIS in determining rates of major depression in the Vietnamese and Arabic community in Australia is questionable. Further studies designed specifically to investigate this are needed.

Modification of perseverative behaviour in an adult with anoxic brain damage

A single-case study is reported of an adult female exhibiting perseverative behaviour on the ward, following anoxic brain damage subsequent to an attempted suicide by hanging. Her behaviour consisted of excessive requests to use the telephone, and was accompanied by a lack of insight, impaired memory and blunted affect, with no evidence of anxiety when prevented from using the telephone. Treatment to reduce the persistent requests was given in two stages, and consisted of feedback, and feedback plus extinction. Results indicated a marked reduction in the perseverative behaviour, though it appeared that this did not generalize to the home environment following the woman's discharge from hospital.

Rapid epidemiologic characterization of cytomegalovirus strains from pediatric bone marrow transplant patients

BACKGROUND

DNA amplification by the polymerase chain reaction (PCR) of human cytomegalovirus (CMV) nucleotide sequences recently has been reported for differentiation of CMV strains.

DESIGN

Retrospective study.

OBJECTIVE AND PATIENTS

Evaluate the strain patterns of 15 CMV-positive buffy coat specimens from five pediatric bone marrow transplant patients.

SETTING

Pediatric bone marrow transplant unit.

METHODS

We perform PCR using primers corresponding to two distinct regions of the CMV genome, the major immediate-early (MIE) region and the a-sequence region, with subsequent restriction enzyme analysis of the amplified products.

RESULTS

Restriction enzyme analysis with Hae III and Hinf I of products amplified with nested PCR for the MIE region revealed distinguishable digestion patterns between patients but similar patterns for samples from each patient. All were distinct from the CMV Towne laboratory control strain. In contrast to these results, amplification of specimens with a-sequence primers, followed by restriction enzyme analysis, did not allow differentiation between all patients.

CONCLUSION

Our results indicate that nested amplification directly from buffy coat specimens using primers for the CMV MIE gene allows rapid CMV strain characterization that is useful for laboratory quality control and epidemiological studies. Distinct CMV strains were found in each patient, suggesting horizontal transmission was not responsible for acquisition of CMV infection in these patients.

Detection of human cytomegalovirus in peripheral blood leukocytes by the polymerase chain reaction and a nonradioactive probe

This study evaluated the effectiveness of polymerase chain reaction (PCR) combined with a nonradioactive probe for the early detection of cytomegalovirus (CMV) in buffy-coat specimens of immunocompromised patients. Dot-blot hybridization with a digoxigenin-labeled probe was used to detect a 262-bp PCR amplified fragment of the major immediate-early gene of CMV DNA. The results were compared with tissue cultures isolation of CMV. The study included 172 buffy-coat specimens from 72 immunocompromised patients. All 28 buffy-coat specimens positive by culture were also positive by PCR. The remaining 144 specimens were negative by culture; however, 47 of these were positive by PCR. Consequently, PCR was in agreement with culture results in 72% of the samples. Of the 47 PCR-positive-culture-negative specimens, 23 were from patients who had positive buffy-coat cultures at other times during their treatment. Chart review showed that an additional 16 of the PCR-positive-culture-negative samples were from patients with clinical evidence of active CMV disease. The eight remaining specimens were from five patients without signs of active disease. Specimens from 11 healthy volunteers were negative by PCR. In this study PCR was shown to be more sensitive than culture because it allowed earlier detection of viremia and demonstrated CMV in buffy-coat specimens that were negative by culture.

Restriction enzyme fragment length polymorphisms of amplified herpes simplex virus type-1 DNA provide epidemiologic information

Human herpes simplex type 1 (HSV-1) DNA of isolates from patients in a large teaching hospital was amplified by the polymerase chain reaction (PCR). The PCR products targeted approximately 2100 nt regions of relatively low G + C content. Comparison of restriction enzyme digests of amplified DNA showed variation useful for strain differentiation. Twelve nonrelated HSV-1 were differentiated from one another. In contrast, specimens epidemiologically related in an outbreak were indistinguishable from each other. Restriction endonuclease analysis of amplified HSV-1 sequences appears to be useful for molecular epidemiology and laboratory quality control to detect possible contamination by PCR products.

Rapid detection of respiratory viruses by shell vial culture and direct staining by using pooled and individual monoclonal antibodies

The Bartels respiratory virus panel detection kit is an indirect fluorescent-antibody (IFA) method that uses pooled and individual antisera for tissue culture confirmation of seven respiratory viruses. We evaluated these reagents for detecting viral antigen in shell vial cultures and by direct staining of cells from respiratory specimens. The isolation from 254 specimens of respiratory viruses in shell vial cultures compared with standard tube cultures was highly sensitive (94%) and specific (97.3%). The numbers of viral isolates detected in three consecutive years of testing with shell vial cultures were 68 of 254 (26.8%), 101 of 381 (26.5%), and 122 of 430 (28.4%). IFA direct staining of all 1,065 specimens resulted in 183 (17.2) being uninterpretable because of inadequate numbers of cells or interfering fluorescence. The sensitivity and specificity of the interpretable IFA direct stains in comparison with shell vial cultures were 85.9 and 87.1%, respectively. For detection of 881 adequate specimens, Bartels respiratory syncytial virus IFA direct staining compared with an Ortho Diagnostics Systems direct fluorescent-antibody test for respiratory syncytial virus RSV was highly sensitive (95.5%) and specific (97%). Shell vial cultures combined with Bartels IFA reagents are a rapid alternative to standard tube cultures. Bartels IFA direct staining with individual antisera provides useful same-day screening of respiratory specimens, but the antiserum pool was not effective in screening for positive specimens because of excessive amounts of nonspecific fluorescence.