title: The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale.
abstract: BACKGROUND
  Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.
  
  
  METHODS
  Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.
  
  
  RESULTS
  Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) 0.01), but not between European countries (∆*CFI < 0.01).
  
  
  CONCLUSIONS
  Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.
authors.affiliation: Department of Psychiatry,The University of North Carolina at Chapel Hill,Chapel Hill, NC,USA.
authors.forename: A
authors.initials: A
authors.lastname: Di Florio
authors.affiliation: Department of Psychiatry,The University of North Carolina at Chapel Hill,Chapel Hill, NC,USA.
authors.forename: K
authors.initials: K
authors.lastname: Putnam
authors.affiliation: Department of Psychiatry,Weill Cornell Medical College,New York, NY,USA.
authors.forename: M
authors.initials: M
authors.lastname: Altemus
authors.affiliation: Erasme Hospital, Paris Diderot University,Paris,France.
authors.forename: G
authors.initials: G
authors.lastname: Apter
authors.affiliation: Department of Psychiatry/Psychology,Erasmus MC,Rotterdam,The Netherlands.
authors.forename: V
authors.initials: V
authors.lastname: Bergink
authors.affiliation: Women's Mental Health, University of Melbourne,Melbourne,VIC,Australia.
authors.forename: J
authors.initials: J
authors.lastname: Bilszta
authors.affiliation: Department of Psychological and Brain Sciences,The University of Iowa,Iowa City,IA,USA.
authors.forename: R
authors.initials: R
authors.lastname: Brock
authors.affiliation: Women's Mental Health, University of Melbourne,Melbourne,VIC,Australia.
authors.forename: A
authors.initials: A
authors.lastname: Buist
authors.affiliation: Departments of Psychiatry and Obstetrics and Gynecology, Hofstra Northwell School of Medicine, Glen Oaks, NY,USA.
authors.forename: K M
authors.initials: KM
authors.lastname: Deligiannidis
authors.affiliation: Erasme Hospital, Paris Descartes University,Paris,France.
authors.forename: E
authors.initials: E
authors.lastname: Devouche
authors.affiliation: Department of Psychiatry,University of Pennsylvania,Philadelphia,PA,USA.
authors.forename: C N
authors.initials: CN
authors.lastname: Epperson
authors.affiliation: Department of Psychiatry,Medical University of South Carolina,Charleston,SC,USA.
authors.forename: C
authors.initials: C
authors.lastname: Guille
authors.affiliation: Department of Psychiatry,University of Pennsylvania,Philadelphia,PA,USA.
authors.forename: D
authors.initials: D
authors.lastname: Kim
authors.affiliation: Department of Medical Epidemiology and Biostatistics,Karolinska Institute,Stockholm,Sweden.
authors.forename: P
authors.initials: P
authors.lastname: Lichtenstein
authors.affiliation: Department of Medical Epidemiology and Biostatistics,Karolinska Institute,Stockholm,Sweden.
authors.forename: P K E
authors.initials: PK
authors.lastname: Magnusson
authors.affiliation: Behavioral Endocrinology Branch,National Institute of Mental Health, National Institutes of Health, Health and Human Services,Bethesda,MD,USA.
authors.forename: P
authors.initials: P
authors.lastname: Martinez
authors.affiliation: Department of Economics and Business,National Centre for Integrated Register-based Research, Aarhus University,Aarhus,Denmark.
authors.forename: T
authors.initials: T
authors.lastname: Munk-Olsen
authors.affiliation: Department of Psychiatry,University of Miami,Miami,FL,USA.
authors.forename: J
authors.initials: J
authors.lastname: Newport
authors.affiliation: Department of Psychiatry,The Johns Hopkins University,Baltimore,MD,USA.
authors.forename: J
authors.initials: J
authors.lastname: Payne
authors.affiliation: Department of Psychiatry,VU University Medical Center,Amsterdam,The Netherlands.
authors.forename: B W
authors.initials: BW
authors.lastname: Penninx
authors.affiliation: Department of Psychological and Brain Sciences,The University of Iowa,Iowa City,IA,USA.
authors.forename: M
authors.initials: M
authors.lastname: O'Hara
authors.affiliation: Department of Family Medicine,Halifax Health,Daytona Beach,FL,USA.
authors.forename: E
authors.initials: E
authors.lastname: Robertson-Blackmore
authors.affiliation: Department of Psychiatry/Psychology,Erasmus MC,Rotterdam,The Netherlands.
authors.forename: S J
authors.initials: SJ
authors.lastname: Roza
authors.affiliation: Department of Psychiatry,Alpert Medical School of Brown University/Rhode Island Hospital,Providence,RI,USA.
authors.forename: K M
authors.initials: KM
authors.lastname: Sharkey
authors.affiliation: Department of Psychological and Brain Sciences,The University of Iowa,Iowa City,IA,USA.
authors.forename: S
authors.initials: S
authors.lastname: Stuart
authors.affiliation: Department of Psychiatry/Psychology,Erasmus MC,Rotterdam,The Netherlands.
authors.forename: H
authors.initials: H
authors.lastname: Tiemeier
authors.affiliation: Department of Medical Epidemiology and Biostatistics,Karolinska Institute,Stockholm,Sweden.
authors.forename: A
authors.initials: A
authors.lastname: Viktorin
authors.affiliation: Behavioral Endocrinology Branch,National Institute of Mental Health, National Institutes of Health, Health and Human Services,Bethesda,MD,USA.
authors.forename: P J
authors.initials: PJ
authors.lastname: Schmidt
authors.affiliation: Department of Psychiatry,The University of North Carolina at Chapel Hill,Chapel Hill, NC,USA.
authors.forename: P F
authors.initials: PF
authors.lastname: Sullivan
authors.affiliation: Department of Psychiatry,University of Arkansas for Medical Sciences,Little Rock,AR,USA.
authors.forename: Z N
authors.initials: ZN
authors.lastname: Stowe
authors.affiliation: Asher Center for the Study and Treatment of Depressive Disorders, Northwestern University Feinberg School of Medicine,Chicago,IL,USA.
authors.forename: K L
authors.initials: KL
authors.lastname: Wisner
authors.affiliation: Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine,Cardiff,UK.
authors.forename: I
authors.initials: I
authors.lastname: Jones
authors.affiliation: Department of Psychiatry,The University of North Carolina at Chapel Hill,Chapel Hill, NC,USA.
authors.forename: D R
authors.initials: DR
authors.lastname: Rubinow
authors.affiliation: Department of Psychiatry,The University of North Carolina at Chapel Hill,Chapel Hill, NC,USA.
authors.forename: S
authors.initials: S
authors.lastname: Meltzer-Brody
mesh_terms: D000293:Adolescent; D000328:Adult; D003431:Cross-Cultural Comparison; D019052:Depression, Postpartum / Q000175:diagnosis* / Q000208:ethnology*; D005260:Female; D006801:Humans; D008875:Middle Aged; D011569:Psychiatric Status Rating Scales; D057566:Self Report; D055815:Young Adult
keywords: Culture; Edinburgh Postnatal Depression Scale (EPDS); education; postpartum depression; race