Literature Review on Postnatal Depressive Disorder (PDD)

Postnatal depression and appropriate screening tools for Aboriginal Australian and Torres Strait Islander peoples – a literature review

Introduction

Postnatal depressive disorder (PDD) is a non-psychotic depressive episode beginning and extending into the first postnatal year1. This unipolar depressive episode is associated with childbirth and refers to women who meet the diagnostic criteria for major or minor depression in the first postnatal year2.  It is associated with an increased risk of future depressive episodes within a 5 year period3. Some risk factors for PDD include depression and anxiety, poor social support and stressful events during pregnancy4,5.  Most estimates indicate that PDD affects between 10-15% of women worldwide6, with rates in Australian found to be at 14%7.  Antenatal risk factors for depression may predict postnatal depression8,9 . As a result, the focus of postnatal depression has broadened to include antenatal depression with the term perinatal depression now describing depressive disorders associated with pregnancy and early parenthood10.

PDD may impact the mother herself, mother-infant interaction11,12, psychological development and long-term health outcomes of the child1,13 . It may impede on a mother’s capacity to nurture her child and is associated with attachment insecurity and increased risk of psychopathological concerns14,15. In addition, as women tend to base self-esteem on their capacity to nurture others, any disruption to this may cause significant consequence on the mother’s self-regard16. It may also have consequences on a capacity to fulfil cultural ideals around the role of a mother and impacting on repercussions for the mother, child and family17.

To detect depression perinatally, the universal screening tool called the Edinborough Postnatal Depression Scale (EDPS) is currently recommended as national tool of choice7,18. This self-reported 10-item questionnaire is considered reliably capable of detecting women who may be at current risk for perinatal anxiety and depression19.  This tool, however, has not been validated for the Aboriginal and Torres Strait Islander peoples20 . Aboriginal people statistically suffer higher incidences of depression and anxiety than non-Aboriginal population21. Historical and sociocultural factors21 including but not exclusive to: colonisation, dispossession and systematic oppression22 are associated with heightened transgenerational-trauma, grief and loss among Aboriginal peoples23. High levels of mental distress, poorer physical and mental healthcare outcomes are also reported across their life24,25.

There are many social stressors and co-morbid health conditions in Aboriginal women’s pregnancy and birth that may contribute to additional risk for postnatal depression. These include but are not exclusive to: low birth weight, perinatal mortality rates twice as high as non-Aboriginal people, higher obstetric loss and bereavement26, elevated incidences of depression, anxiety and PTSD2. Additional risk factors for depression perinatally include: unemployment, low socio-economic status, childhood abuse, personality type, marital disharmony, stressful life events and social support27-29.

The prevalence of psychosocial stressors such as low partner support and major life events were significantly elevated among Aboriginal women in research literature30.  Research indicates that Aboriginal women who are pregnant also have fewer antenatal visits and less postnatal care than non-Aboriginal mothers31. These combined factors highlight the need for screening and early intervention for postnatal anxiety and depression as they could result in significant health benefits to the mother and child.

The following literature review will discuss mental health in Aboriginal peoples, the EPDS screening tool, how appropriate it is for Aboriginal people and novel screening tools such as the Kimberly Mum’s Mood Scale (KMMS). It will primarily focus on Aboriginal peoples in the Kimberley and Pilbara region of Western Australia. Aboriginal and Torres Strait Islander peoples will hereby be referred to as Aboriginal peoples as the populations in the aforementioned communities have a high proportion of Aboriginal people.

Depression and anxiety in Aboriginal and Torres Strait Islanders

Aboriginal cultural views of mental ill health is viewed as holistic, where well-being is understood in terms of the harmonised interrelations between spiritual, environmental, ideological, political, social, economic, mental and physical domains21. For Aboriginal peoples, a concept of self also encompasses the individual, together with their family, the wider tribal group and reciprocal obligations, loss or disintegration of which will to mental ill health32. Since colonisation, these traditional connections have been severely disrupted by cultural genocide, dislocation, forced removal of children, destruction of culture as well as devastating denial of basic human rights33. The consequence is an overwhelming sense of trauma, loss and grief for Aboriginal peoples.  As a result, there are two dimensions of mental health among Aboriginal Australians21. One is ‘mental distress’ resulting from collective experience as dispossessed and disadvantaged peoples and the other incorporates a range of serious psychiatric or mental disorders which are also prevalent in Aboriginal communities but may manifest differential or be understood differently34.

There is poor understanding of Aboriginal mental health including the definitions, manifestations and conceptualisations of illness which may contribute to limited epidemiological data surrounding mental illness in Aboriginal people21. Aboriginal Australians have, however, consistently been shown to have a higher prevalence of psychological distress35; ranging from 50% to 3 times higher36.  There is an associated increase in levels of distress in victims violence, discrimination or removal from natural37. Additional adverse social factors (e.g. poverty, lack of support, substance use) that are more prevalent among Indigenous peoples worldwide also cause greater risk for depression38. This is an important factor in Aboriginal suicide as depression has been documented in many settings to be a significant component of high suicide rates and both depression and suicide have been documented to be common amongst Aboriginal people39. Studies show that the rates of Aboriginal suicide are twice as high as non-Aboriginal peoples in Queensland40 and some limited research data indicates that the incidence is increasing in the Kimberley in recent decades41.

Edinborough Postnatal depression scale:

The Edinborough postnatal depression scale (EPDS) is the most widely used scale questionnaire for PPD. It is a 10-item self-report questionnaire in which women are asked to rate how they have felt in the previous 7 days. Each question is scored 0-3 and takes 5 minutes for completion19. Once scored, the screening instrument is used to assess the likelihood of depression and subsequent clinical diagnosis can be made by the appropriate trained health professional7. The EPDS has been translated to and validated in many languages other than English. These languages include French, Italian, Spanish, Norwegian, Arabic, Bengali and Indonesian7.

Some studies have shown the need for appropriately translated and carefully piloted versions of the EPDS in non-English speaking groups within Australia. Limited literature about the use of EPDS across culturally and linguistically diverse (CALD) and English-speaking populations exist. However, limited research and differences in study design suggest that results of EPDS must be interpreted with caution42. The Likert-type scales (used in EPDS) which are graded are also considered problematic in CALD populations, especially with individuals who have little formal education43. A paper by Stapelton et al.  explored the utility of EPDS in refugee populations, indicating that the tool is often culturally inappropriate and women couldn’t identify with it42. As a result, clinicians are advised to exercise clinical judgement and consider employing lower cut-off scores when administering EPDS to child-bearing women from CALD backgrounds44.

Appropriateness of EPDS for Aboriginal women:

There is also limited information about the validity and reliability of EPDS in the Aboriginal population. The available studies indicate that Aboriginal women find the language complex often misinterpreted it, reducing its usefulness and hence uptake among healthcare professionals45. Current research indicates that only 17% of women attending primary healthcare centres for maternity care are  (this varied from 5-38% depending on the state of Australia)), with the EPDS used 96% of the time29. A study by Campbell et al. also investigated the usefulness of a translated EPDS through extensive community for the Mount Isa population and Community Controlled Townsville Aboriginal and Islander Health Service7. Authors, however, noted that the tools were linguistically inappropriate as they translated the ten items in the EPDS questionnaire into terminology relevant to the community but based on a European (Western) construct of anxiety and depression7.

In addition, the tool has not been validated against standard assessment and hence the capacity of it to identify Aboriginal experience and emotional distress is unknown46. Other identified problems with the study include tools being based on Mount Isa and Townsville populations and so widespread use of these translated measures may be inappropriate as Aboriginal populations are heterogeneous and its relevance to other communities is unknown46. Given that EPDS is based on a Western psychological theory and assessments may be inappropriate to use46. The current lack of psychological measures that are respectful of Aboriginal culture is a potential contributing factor in the continued disadvantage experienced by Aboriginal people47. Hence, linguistic, cultural and practical reasons have highlighted the need for an alternative approach to screening tools for Aboriginal populations.

Postnatal depression and factors contributing to poor detection among Aboriginal women:

Aboriginal women have a birth rate of 2.57 children as compared to 1.9 in the general population38. Aboriginal peoples form 2.5 percent of the total Australian population48 but research of Aboriginal women’s rates and experience of postnatal depression, however, is limited. A beyondblue report in 2005 found that Aboriginal women have a heightened risk of depression. The EPDS > 12 (indicating probably depression18) in Aboriginal woman was 12% compared with 7.6% in Australia, conferring twice the risk of postnatal depression49. In another study, the distress rates were 28% as compared to 17% in the perinatal period30. The higher rates of the second study, however, this may be due to the sensitivity of the screening tool in Queensland population or the small sample size30.

In the Kimberley, Aboriginal women may find it difficult to express their feelings as being a strong mother can play an important cultural role2. When assessed for depression, some Aboriginal women may not identify well with a ‘Western’ approach to health care and as a result they may not be recognised as experiencing depression or anxiety50. As Aboriginal women often have more serious health problems, pinpointing mental health issues on a background of this can add additional complexity2. In addition, cultural division within many healthcare professionals (HCPs) can lead to limitations by their own worldview51. This highlights the need for a standardised screening assessment to accurately identify risk of anxiety and depression postnatally among Aboriginal women.  When mental health issues are identified, individuals may not be offered solutions that are suitable to them and may be simple irrelevant50. The integration of culturally and language appropriate social and emotional tools, strategies and services in Aboriginal settings is may assist to address high levels of psychological distress50,52.

Another factor contributing to poor detection may be Aboriginal women’s concern that disclosing illness or disability to lead to removal of their child53. This experience of illness may cause concealment or denial and unwillingness to engage in mental health services53. Fear of forced child removal is often present in the minds of Kimberley women today as so many families suffered personal and direct loss as part of the stolen generation2.

Kimberley Mum’s Mood Scale:

Extensive community consultation in the Kimberley has demonstrated the need for cultural safety in the screening instrument and adequate ‘yarning time’ 54. The locally developed, culturally appropriate Kimberley Mum’s Mood Scale (KMMS) was developed to assess anxiety and depression and improve rates and help provide better care for social and emotional health of Aboriginal women in the perinatal period23. The KMMS tool was developed by Kimberley healthcare providers in collaboration with over 100 Aboriginal women from eight Kimberley language groups (lead by Al Kotz)2.

The two-part KMMS has been designed to be administered by a range of health care professions including midwives, child health nurses and other providers of perinatal care55. The first part covers the same areas as the EPDS using similar stems and scoring systems55. This was development of wording began using the Mt Isa and Townsville translated versions of EPDS7. It was then further adapted to use ‘Kimberley’ English, locally developed graphics and a visual Likert scale (focusing on feelings not numbers)21. Part 2 is a psychosocial tool that incorporates key elements identified by Kimberley Aboriginal women, enabling a score from Part 1 to be put into context, and supporting a mental health brief intervention and development of an appropriate plan21. This was developed as a result of multiple focus groups providing input for words, visuals and a protocol for administration which highlighted the need for the second part2.

This tool has been found to be a culturally safe and non-judgmental tool. The HCP who used it also found they that gained valuable insight into participant’s lived experiences and social, emotional and cultural well-being55. Such an understanding may assist in early identification of mental health issues increase capacity to shape supportive ongoing care55. The KMMS has also been validated and found to be more readily accepted by participants and clinicians than the EPDS and has potential to lead to more timely and supportive interventions for Kimberley Aboriginal women23.

In addition, the sensitivity of KMMS using a cut-point between low and moderate were able to detect anxiety and depressive disorders compares well with sensitives reported in a systematic review of EPDS23. Research indicates that the KMMS tool is able to detect women urgently requiring immediate assistance (moderate or high severity anxiety and/or depression) and exploring protective and risk factors during part 2’s mental health brief-intervention supported appropriate assistance for women at lower risk55.  The combination of its acceptability and sensitivity indicate that this screening tool may could have greater uptake by HCPs in the Kimberley. There are, however, no studies about the sensitivity and acceptability of KMMS in other Aboriginal communities outside of the Kimberley.

Gap in the literature and Future directions

The Pilbara region comprises approximately 20% of the total land mass of Western Australia56. Much of the region is desert and sparsely populated with most of the population clustered around a few major towns. In total, there are approximately 50,000 residents of whom 16% are Aboriginal peoples57. Pilbara residents tend to experience poorer health than residents in other parts of Western Australia57,58. There is considerably higher levels of smoking and alcohol consumption, obesity and lower amounts of fresh fruit and vegetable consumption, especially in remote Aboriginal communities59,60. Another strong element that contributes to poorer health among Pilbara residents is the lack of timely and effective primary healthcare which could act in a preventive fashion61. Current general health services fail to sufficiently address the needs of Aboriginal peoples61. This highlights the stronger need for screening tools which can accurately identify individuals in need and assist in specifying a targeted management plan.

There is, however, very little published information about rates of depression and PDD in Pilbara Aboriginal peoples. Currently there is no culturally appropriate and validated screening tool for perinatal depression among Aboriginal women in the Pilbara. Current strategies for exploring the use of KMMS in the Pilbara region are limited to training programs such as ‘train the trainer’ education will be provided for Maternal and Child Health program team leaders and co-cordinators by the Kimberley team in the Pilbara region to understand the KMMS for future exploration of its’ appropriateness55. It is plausible that the KMMS or a modification of the KMMS may be useful in the Pilbara. Future research will need to involve consultation with local community groups about the KMMS to explore if this tool or an adaptation of this tool is culturally and linguistically appropriate for Pilbara Aboriginal women.

Conclusion

Western concepts of mental health and perinatal depression in the EPDS are not always concordant with the way psychological distress manifests among Aboriginal mothers. Aboriginal peoples have different cultural reviews regarding ill health which integrate holistic concepts of family, kinship and community, political, socioeconomic, spiritual and environmental domains. As a result, their perception of mental illness and beliefs around it may vary from current Western psychological theory and screening tools based on this may not be appropriate or sensitive. Adapting the current KMMS to Pilbara Aboriginal communities should be explored to see if this tool or an adaptation of it is culturally and linguistically appropriate for Pilbara Aboriginal women. Future research tools that can identify with specificity and sensitivity postnatal depression in Pilbara Aboriginal women may assist in early intervention in the Aboriginal population, which currently exhibits high rates of mental health distress and physical morbidity.

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