Risk factors for postpartum depression: the role of the Postpartum Depression Predictors Inventory-Revised (PDPI-R). Results from the Perinatal Depression-Research & Screening Unit (PNDReScU) study.

The aims of this study were to identify the frequency of the risk factors for postpartum depression (PPD) listed in the Postpartum Depression Predictors Inventory-Revised (PDPI-R) during pregnancy and 1 month after delivery and to determine the predictive validity of the PDPI-R. The study used a prospective cohort design. Women completed the PDPI-R at the 3rd and the 8th months of pregnancy and at the 1st month after childbirth. Women were prospectively followed across three different time points during the postpartum using Structured Clinical Interview for DSM-IV Disorders to determine the presence of major or minor depression. The prenatal version of the PDPI-R administered at two different time points during pregnancy predicted accurately 72.6% and 78.2% of PPD and the full version administered at the 1st month after delivery predicted 83.4% of PPD. The cutoffs identified were 3.5 for the prenatal version and 5.5 for the full version. The PDPI-R is a useful and a valid screening tool for PPD.

Ensuring content validity: an illustration of the process.

Assessing content validity is one of the most critical steps in instrument development. Neither statistical elegance nor sophisticated measurement strategies are substitutes for validity. Systematic in-depth approaches to the assessment of content validity are needed, including a priori and a posteriori procedures. In this manuscript the a priori approach of specifying an instrument's content domain is addressed along with the a posteriori procedure of having a panel of judges assess the validation of the items. This article focuses on the process used to assess the content validity. Data from the psychometric testing of the Postpartum Depression Screening Scale (PDSS) are used to illustrate this process. The PDSS is a Likert-type self-report composed of seven dimensions: Sleeping/Eating Disturbances, Anxiety/Insecurity, Emotional Lability, Cognitive Impairment, Loss of Self, Guilt/Shame, and Contemplating Harming Oneself. Items on the PDSS were generated from a series of qualitative research studies on postpartum depression. Content validity was assessed using two approaches to review the scale: (a) a panel of five content experts with professional expertise in postpartum depression, and (b) a focus group of 15 nurses knowledgeable in the field.

Predictors of postpartum depression: an update.

BACKGROUND: Approximately 13% of women experience postpartum depression. Early recognition is one of the most difficult challenges with this mood disorder because of how covertly it is suffered. OBJECTIVES: The purpose of this meta-analysis was to update the findings of an earlier meta-analysis of postpartum depression predictors that had synthesized the results of studies conducted mostly in the 1980s. METHOD: A meta-analysis of 84 studies published in the decade of the 1990s was conducted to determine the magnitude of the relationships between postpartum depression and various risk factors. Using the software system Advanced Basic Meta-Analysis, effect sizes were calculated three ways: unweighted, weighted by sample size, and weighted by quality index score. RESULTS: Thirteen significant predictors of postpartum depression were revealed. Ten of the 13 risk factors had moderate effect sizes while three predictors had small effect sizes. The mean effect size indicator ranges for each risk factor were as follows: prenatal depression (.44 to .46), self esteem (.45 to. 47), childcare stress (.45 to .46), prenatal anxiety (.41 to .45), life stress (.38 to .40), social support (.36 to .41), marital relationship (.38 to .39), history of previous depression (.38 to .39), infant temperament (.33 to .34), maternity blues (.25 to .31), marital status (.21 to .35), socioeconomic status (.19 to .22), and unplanned/unwanted pregnancy (.14 to .17). CONCLUSIONS: Results confirmed findings of an earlier meta-analysis and in addition revealed four new predictors of postpartum depression: self-esteem, marital status, socioeconomic status, and unplanned/unwanted pregnancy.

Comparative analysis of the performance of the Postpartum Depression Screening Scale with two other depression instruments.

BACKGROUND: Postpartum depression affects approximately 13% of mothers but up to 50% of all cases of this tragic illness can go undetected. OBJECTIVE: The purpose of this study was to compare the performance of a newly created instrument, the Postpartum Depression Screening Scale (PDSS), with the Edinburgh Postnatal Depression Scale (EPDS) and a general depression scale, the Beck Depression Inventory-II (BDI-II). METHOD: In this methodological design a total of 150 new mothers completed these three instruments in random order, followed immediately by a DSM-IV diagnostic interview. Using the LABROC I program, the areas under each of the instrument's Receiver Operator Characteristic (ROC) curves were compared to determine if they were significantly different. RESULTS: Eighteen (12%) of the women were diagnosed with major postpartum depression, 28 women (19%) with minor postpartum depression, and 104 women (69%) with no depression. Compared to the EPDS, the PDSS had a significantly larger area under the ROC curve when screening for major or minor postpartum depression. When using the published recommended cut-off scores for major depression for the three instruments, the PDSS achieved the highest combination of sensitivity, 94%, and specificity, 98%. When detecting women with major or minor postpartum depression, the PDSS again yielded the highest combination of sensitivity (91%) and specificity (72%) of the three instruments. The PDSS identified 17 (94%) of the women diagnosed with major postpartum depression, the EPDS identified 14 of these women (78%), and the BDI-II identified 10 of the 18 women (56%). CONCLUSION: If mothers identified as "most depressed" are substantially determined by the instrument used, the implications for both research and clinical practice are significant. Researchers and clinicians need to be aware of the differential sensitivity of depression instruments which, while supposedly measuring the same construct, are focused on different components of this mood disorder.

Item response theory in affective instrument development: an illustration.

The benefits of item response theory (IRT) analysis in obtaining empirical support for construct validity make it an essential step in the instrument development process. IRT analysis can result in finer construct interpretations that lead to more thorough descriptions of low- and high-scoring respondents. A critical function of IRT is its ability to determine the adequacy with which the attitude continuum underlying each dimension is assessed by the respective items in an instrument. Many nurse researchers, however, are not reaping the benefits of IRT in the development of affective instruments. The purpose of this article is to familiarize nurse researchers with this valuable approach through a description of the Facets computer program. Facets uses a one parameter (i.e., item difficulty) Rasch measurement model. Data from a survey of 525 new mothers that assessed the psychometric properties of the Postpartum Depression Screening Scale are used to illustrate the Facets program. It is hoped that IRT will gain increased prominence in affective instrument development as more nurse researchers become aware of computer programs such as Facets to assist in analysis.

Further validation of the Postpartum Depression Screening Scale.

BACKGROUND: Up to 50% of all cases of postpartum depression go undetected. The Edinburgh Postnatal Depression Scale (EPDS) has been the only instrument available that was specifically designed to screen for this mood disorder. None of the items on the EPDS, however, are written in the context of new motherhood. OBJECTIVE: The purpose of this study was to further assess the construct validity of the newly designed Postpartum Depression Screening Scale (PDSS) along with its sensitivity, specificity, and predictive values. METHOD: A total sample of 150 mothers within 12 weeks postpartum participated in the study. Each mother completed in random order three questionnaires: The PDSS, EPDS, and The Beck Depression Inventory-II (BDI-II). Immediately after completing these three questionnaires, each woman was interviewed by a nurse psychotherapist using the Structural Clinical Interview for DSM-IV Axis 1 Disorders. RESULTS: Twelve percent (n = 18) of the mothers were diagnosed with major postpartum depression, 19% (n = 28) with minor postpartum depression, and 69% (n = 104) with no depression. The PDSS was strongly correlated with both the BDI-II (r = 0.81) and the EPDS (r = 0.79). The ability of the PDSS to explain variance in diagnostic classification of postpartum depression above that explained by the BDI-II and EPDS (i.e., incremental validity) was assessed using hierarchical regression. After explaining variance in group classification by the other two depression instruments, the PDSS explained an additional 9% of the variance in depression diagnosis. Using receiver operating characteristic (ROC) curves, a PDSS cut-off score of 80 (sensitivity 94% and specificity 98%) is recommended for major postpartum depression and a cut-off score of 60 (sensitivity 91% and specificity 72%) for major or minor depression. CONCLUSION: Based on the results of this psychometric testing, the PDSS is considered ready for use in routine screening of mothers.

Caring within nursing education: a metasynthesis.

During the 1990s qualitative research studies on caring within schools of nursing have been conducted. What generalizations can be made from these qualitative research studies that can effectively be used to promote the development of a caring community in nursing education in the 21st century? A metasynthesis of 14 qualitative research studies on caring among faculty and students was conducted. Noblit and Hare's metaethnographic approach was used. The metasynthesis revealed five metaphors or themes that permeated caring in nursing education. These metaphors centered on reciprocal connecting that consisted of presencing, sharing, supporting, competence, and uplifting effects of caring. Implications of this metasynthesis for nursing educators are addressed.

Trends in nursing education since 1976.

Since the first issue of MCN was published, many changes have transpired in nursing education on all levels. These trends in nursing education since 1976 are addressed for diploma, associate, baccalaureate, master's, and doctoral programs. Examples of such trends focus on enrollments, graduations, and minority students. Trends to watch for in nursing education over the next quarter century are forecasted along with recommendations for nurse educators.

Postpartum Depression Screening Scale: development and psychometric testing.

BACKGROUND: Approximately 400,000 mothers in the United States experience postpartum depression each year. However, only a small proportion of these women are identified as depressed by health care professionals. OBJECTIVES: To improve detection of this postpartum mood disorder, the purpose of this study was to assess the psychometric properties of a newly devised instrument, the Postpartum Depression Screening Scale (PDSS), a 35-item Likert-type self-report instrument. METHODS: Content validity was supported through the literature and the judgments rendered by a panel of five content experts and a focus group. The PDSS was administered to 525 new mothers. RESULTS: Confirmatory factor analysis provided empirical support for the existence of the hypothesized seven dimensions. A Tucker-Lewis goodness-of-fit index of 0.87 and a root mean square residual of 0.05 were judged supportive of model fit. Item response theory techniques provided further construct validity support for finer interpretations of the respective seven dimensions. Analysis of the Likert 5-point response categories further supported meaningful score interpretations. Alpha internal consistency reliabilities ranged from 0.83 (sleeping/eating disturbances) to 0.94 (loss of self). CONCLUSIONS: Empirically, all of the reliability and validity analyses supported the score interpretations posited for the PDSS. Currently, the sensitivity, specificity, and positive predictive value of the PDSS are being determined.

Quantitative measurement of caring.

Caring is a difficult, elusive concept not only to define but also to measure. Eleven different quantitative instruments designed to measure caring are reviewed. Out of these 11 caring instruments, seven are Likert scales, two are visual analogue scales, one is a checklist, and one is a Q-sort. For each of these instruments the following information is provided: description of the tool, such as number of items and length of time to administer; conceptual definition of caring upon which it is based; reported reliability and validity; and the instrument's use in research studies. Comparison of these instruments revealed that different aspects of caring are measured by these tools such as caring behaviours, satisfaction with caring behaviours, ability to care, and response to caring behaviours. Some caring instruments are designed to be completed by patients only, by nurses only, or by either patients or nurses. Multiple factors need to be taken into consideration by nurse researchers in deciding which instrument to use to measure caring.

Maternal depression and child behaviour problems: a meta-analysis.

Children of depressed mothers are not only at risk for the development of psychopathology, but also for behaviour problems. A meta-analysis of 33 studies was conducted to determine the magnitude of the relationship between maternal depression and behaviour problems in children 1 year of age and older. Substantive, methodological, and miscellaneous variables were extracted and coded by both the researcher and a research assistant. The initial inter-rater agreement reached in coding these variables ranged from 85% to 100%. Effect sizes were calculated in three ways: unweighted, weighted by sample size, and weighted by quality index score. The mean effect size for the r index ranged from 0.29 when weighted by sample size to 0.35 when unweighted, indicating a moderate relationship between maternal depression and child behaviour problems. Children between the ages of 1-18 whose mothers were depressed displayed more conduct behaviour problems than children whose mothers were not depressed. The magnitude of this relationship covaried significantly with the predictors of sample size and quality index scores. Implications for future research are addressed.

Content validity exercises for nursing students.

In instrument development, the assessment of content validity is a critical step. However, content validation often is given superficial and cursory attention. Because the procedure involved in assessing content validity is not addressed in depth in research textbooks, nursing students may not fully understand or appreciate the intricacies required in this crucial process. The purpose of this article is to share some content validity exercises the author has developed for use with both undergraduate and graduate nursing students. These exercises involve an instrument, entitled the Postpartum Depression Screening Scale, which the author is currently developing.

Available instruments for research on prenatal attachment and adaptation to pregnancy.

Research, clinical practice, and cost-effective nursing care are all interrelated and are dependent on the use of reliable and valid instruments. Critical to the success of any research study is the choice of instruments to measure key variables. Locating existing instruments for use in nursing research is an important but often labor-intensive activity. This article provides a review of some available instruments that measure two key clinical phenomena particular to the prenatal period: maternal-fetal and paternal-fetal attachment and adaptation to pregnancy. Examples of specific nursing studies that utilize these instruments are presented along with an assessment of the instruments' reliability and validity. Both nurse researchers and clinicians can benefit from this review of selected instruments used during the prenatal period.

Facilitating the work of a meta-analyst.

Meta-analysis facilitates the transfer of knowledge from nurse researchers to clinicians. In this article, the benefits and criticisms of meta-analysis for nursing are identified along with the specific problems a meta-analyst may encounter in conducting a quantitative analysis and synthesis of the literature. Problems in data retrieval from the primary studies for a quantitative literature review can plague a meta-analyst. These problems can include insufficient data such as inexact p-values, incomplete descriptions of samples or experimental and control groups, and errors in tables in research reports. Suggestions for removing some of these roadblocks are addressed along with recommendations to authors, editors, and manuscript reviewers. An example of a suggestion for authors is to focus on reporting exact statistical values and p-levels. Also, sample characteristics and methodological variables are deserving of detailed descriptions in research reports. Editors can consider including a summary table of basic descriptive and inferential statistics. Another recommendation for editors is to develop a reviewer's checklist to ensure the author has included all relevant statistical information and study characteristics a meta-analyst needs.

Opening students' eyes. The process of selecting a research instrument.

The selection of a research instrument to collect data is crucial to the success of a study. This choice can be one of the most time-consuming and challenging tasks in the research process. If they have not been involved in conducting a research study themselves, nursing students are unaware of the intricacies involved in the decision-making process for selection of an instrument. The author describes a teaching strategy to help nursing students appreciate the many components involved in this critical and challenging step in the research process. The example used is from the author's research program on postpartum depression, which describes step by step the author's decision-making process for selection of an instrument.

Postpartum onset of panic disorder.

PURPOSE: To describe the experience of panic disorder in mothers during the postpartum period. The onset of panic disorder during the postpartum period has recently been reported. Clinicians are urged to differentiate between the more widely known presentation of postpartum depression and the newly reported postpartum panic disorder. DESIGN: Phenomenology. The purposive sample consisted of six women with panic disorder during the postpartum period. METHODS: In 1995, mothers were interviewed regarding their experiences with panic. The verbatim transcripts of these interviews were analyzed using Colaizzi's phenomenological method. In all, 214 statements regarding mothers' experiences of panic were extracted and clustered into six themes. FINDINGS: Panic during the postpartum period seriously complicated mothers' lives as they struggled to maintain their composure during panic attacks. As a result of recurring panic attacks, negative changes in women's lifestyles ensued stripping them of their self-esteem and leaving them to bear the burden of disappointing not only themselves, but also their families. CLINICAL IMPLICATIONS: Implications for nursing practice with mothers suffering from postpartum onset of panic disorder can be derived from each one of the six themes. Nurses can help women identify panic triggers to help prevent further panic attacks. Also, nursing interventions can target the guilt mothers experience over repeatedly disappointing themselves and their families.

A review of research instruments for use during the postpartum period.

Locating existing instruments available to measure key variables is critical to the success of a research study. However, this process can be a time-consuming activity. In this article, selected instruments available for use in research during the postpartum period are reviewed. These instruments are divided into two categories. The first category deals with instruments that focus on mothers only. These questionnaires measure mothers' perceptions of their deliveries, their adaptation to motherhood, and their breastfeeding experiences. The second category centers on instruments that both parents can complete. These instruments measure parents' perceptions of their parenting role, sense of competence, problem-solving ability, and perceptions of their newborns. The psychometric properties of each instrument are described, and selected nursing research studies that used the instrument are reviewed.