Brief reportAre we overpathologising motherhood?
Introduction
Perinatal distress, a term that encompasses disorders of depression and anxiety, either during pregnancy or the first 12 months postpartum, is serious and reportedly prevalent. Rates of depression are typically reported to be around 10–15% (e.g., Buist et al., 2008, Baker et al., 2005), and these rates will be higher when anxiety disorders are also included (Wenzel et al., 2003). The impact of depression on the foetus, infant, toddler and partner has been shown to be significant (e.g., Deave et al., 2008, McGrath et al., 2008, Matthey et al., 2000, Trapolini et al., 2008). Anxiety has also been shown to have detrimental effects (e.g. on the foetus: Glover and O'Connor, 2002).
That this condition has been recognised and identified is clearly beneficial to the well-being of families. Initiatives to implement routine screening for these conditions are also beneficial (e.g. Matthey et al., 2004), if this can help ameliorate, or prevent, such mood disorders in women.
The purpose of this paper however is to question whether we are now overpathologising ‘motherhood’. This is not to question the seriousness of perinatal mental health difficulties, nor the need to accurately identify women or men with significant difficulties or risks early in the process. Instead this paper puts forward an argument that many women (and possibly men) are being incorrectly identified as having clinically significant distress, or have risks that predict they may develop this level of distress. If this is in fact the case, it is likely that a more accurate assessment in the perinatal period will allow clinical services to better target those women or men who are experiencing significant distress, or are likely to become significantly distressed, and thus use the limited health resources more efficiently.
Section snippets
Do ‘high scores’ on self-report mood scales represent likely depression?
Self-report mood measures, such as the Edinburgh Depression Scale (Cox et al., 1987), the Beck Depression Inventory (Beck et al., 1961), and the CES-D (Radloff, 1977) are often used to report probable rates of depression in perinatal women. Clinically other information is also used to determine each individual's emotional experience.
For the EDS, which is the most commonly used measure, the validated cut-off score is 13 or more for probable major depression in English-speaking postpartum women.
The use of a single high self-report score to determine probable distress
Cox and Holden (2003) stated that:
“One high score (on the EDS) may indicate only that the woman is feeling temporarily over-whelmed by her circumstances or that she is tired and miserable on a particular day. Two high scores separated by 2 weeks, plus an interview, will usually confirm depression” (p. 61).
Yet only two studies, to my knowledge, have followed this advice when reporting the rate of probable depression based upon high EDS scores. Ballestrem et al. (2005) stated that “(doing the
Incorrect cut-off scores on scales used to determine ‘probable distress’
Many studies use incorrect cut-off scores on the EDS (e.g., 12 or more instead of the validated 13 or more; or the antenatal use of the lower postnatal cut-off score; Matthey et al., 2006). This can overestimate the rate of high scorers by 30%. Unfortunately there continue to be publications using, or recommending, incorrect cut-off scores on the EDS (e.g., Campbell et al., 2008, Rychnovsky and Brady, 2008, Sword et al., 2008), thus inflating the rate of probable depression. Using such
Diagnostic criteria may overpathologise normal experiences of parenthood
The ‘gold standard’ for diagnosing depression in the perinatal period is whether or not the individual meets the criteria for major depression as set out in DSM IV (or the similar ICD).
DSM IV diagnoses have the following nine symptoms:
- 1.
Depressed mood
- 2.
Anhedonia
- 3.
Weight or appetite change
- 4.
Sleep disturbance
- 5.
Observable psychomotor activity
- 6.
Fatigue
- 7.
Lack of self-worth
- 8.
Concentration difficulties
- 9.
Thoughts of death.
- 3.
For major depression the client needs to have at least 5 symptoms, with either #1 or #2 present.
At-risk criteria
The arguments so far have focused on the interpretation of scale scores or symptoms. Also relevant to considering whether we are overpathologising motherhood is the classification of women as being ‘at-risk’ of developing postnatal distress or depression.
While there are different ways of determining such a classification (e.g., Austin et al., 2005, Carroll et al., 2005, Matthey et al., 2004), all of which are based on well-documented risk factors for pnd, in many instances the percentage of
Conclusion
This paper has put forward the argument that rates of probable postnatal distress, or risks for becoming distressed, are usually substantially overinflated due to weaknesses in our measures, procedures, or interpretations. Five pieces of evidence are described supporting this argument:
- 1)
Approximately half the women who score high on the most commonly used self-report scale, the EDS, actually meet criteria for depression in validation studies.
- 2)
No differentiation is usually made between women with
Role of funding source
There was no external funding involved with this manuscript.
Conflict of interest
There is no known conflict of interest.
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