Cross-cultural Use of the Edinburgh Postnatal Depression ScalePosted by Marcia Carteret, M. Ed. in Behavioral Health, Blog, Cultural Health Beliefs + Behaviors, Immigrant and Refugee Health, Mental Health, Special Topics, Talking to Patients
Although the cultural aspects of the pregnancy-related period in women’s lives have been studied extensively worldwide, the impact of cultural factors upon pregnancy-related depression has been investigated far less. Most research into pregnancy-related depression has been conducted in Western Europe, the U.S., Canada, and Australia. This research has been based primarily on studies of Western people by mental health professionals raised in Western cultures. Most psychological phenomena, however, are intrinsically culture bound and psychological theories developed in one culture may not automatically be generalizable to the behavior of the people of another culture. (Azuma, 1984)
This reasoning should be applied to use of EPDS in cross-cultural encounters with patients and families in the U.S., especially with recent immigrants and refugees from non-western countries who are unfamiliar with western medicine. Mental/behavioral health concepts are often especially difficult to discuss meaningfully with these populations. Language barriers too must be closely attended. Consideration must be paid to identifying what is culturally specific in mainstream “Western” psychology, and then adopting new concepts applicable to other cultures is key. There is no possibility of providing culturally-responsive care to women and others in their lives without attempting with true diligence to understand the meaning and importance they themselves assign to pregnancy-related “depression.”
Listed below are some specific considerations of using EPDS in cross-cultural encounters:
(These apply to use of validated translations of the EPDS as well as use of the English version.)
- In some cultures, women may experience unhappiness after childbirth comparable to pregnancy-related depression, but may not conceive of this “unhappiness” as an illness or as related to pregnancy. Often, emotional problems are expressed as physical (somatic) problems or concerns for the baby instead of being “depressed.” The EPDS does not contain questions that correlate with the unique ways a woman may use physical explanations. Additionally, in some languages there is no word which literally means depression, much less pregnancy-related depression.
- Stigma is also a block to conversation about EPDS results. Any implication of depression might be interpreted simply as bad mental health or even psychosis by some cultures. Mental health labels can be damaging across the extended family and can reduce a family’s status in its community. In cross-cultural health care the importance and power of family can not be underestimated. It is better for providers to use terminology related to sadness or to try to speak about physical symptoms such as sleeplessness when discussing EPDS results.
- The concept of “questionaires” in general is very much embedded in western culture. Incidentally, the questionnaire was invented by the Statistical Society of London in 1838. Today it is so much a part of the U.S. data-driven culture, we expect questionnaires in every setting – in grocery stores, gyms, workplaces, and of course in our doctor’s offices. This is not true in many places in the world. Thus, any questionaire like EPDS, even if it is written in a language that can be read by a woman who is also sufficiently literate, can be cause for bewilderment and perhaps even anxiousness. Thus, the answers provided may not be an accurate reflection of emotional problems in the perinatal period.
- It is not uncommon in cross-cultural situations for a woman’s spouse, mother-in-law, or other third party to fill out out the questionaire. The woman/patient may not even be encouraged to contribute her experience by the person who is answering the questions for her. In most cases, this is done by a family member to be supportive, and may be culturally appropriate. However, it is a misuse of the EPDS. The developers of the EPDS themselves suggested the screening tool should not be filled out by a third party, eg. a mother-in-law, or even in the presence of a third party who is aware of the mother’s responses to the EPDS (Cox & Holden, 1994). Providers must have a way to address this situation which occurs frequently, especially with immigrant and refugee families.
Cox, J.L. (1994) Origins and development of the 10 Item Edinburgh Post-Natal Depression Scale in Perinatal Psychiatry: Use and Misuse of Edinburgh Post-Natal Depression Scale. (Cox J.L. and Holden J.M. eds). Gaskell, London pp. 115-124