EPDS and Perinatal depression: cultural variations and issues

Perinatal depression (PND) is probably a universal experience. However, there are variations across cultures in the manner that PND is evident and the meaning and importance assigned to it by women and others in their lives and by the larger community/society (Department of Health, Government of Western Australia, 2006).

Specific areas to be aware of include the:

• The level of education and literacy: this must be ascertained for every person completing the EPDS.
• The culture of completing questionnaires: even if the EPDS is written in a language that can be read and the woman is sufficiently literate, the experience of completing questionnaires can be bewildering if a woman has never answered a questionnaire on her own.
• The EPDS should be completed by the woman and a plan should be developed in partnership with the woman with regards to who will be told. (Cox & Holden, 1994).
• Official and non-official languages and dialect differences: many countries have one or more official languages and other languages that are spoken but not recognised as official languages. Also, there can be a number of dialects that are often not understandable by others. The translated version may only make sense to the people who are conversant in the particular language or dialect in which the test was constructed.
• Urban-rural differences: there may be vast cultural differences in language between women in urban and rural areas of countries.
• Expression, presentation, discussion of and about depression: in some cultures, eg Japanese women tend to express emotional problems by referring to physical (somatic) problems or concerns for the baby rather than expressing their feelings when they are depressed. The EPDS does not contain any somatic items which might raise practical problems if the dominant way in which depression presents is a physical (somatic symptom).
  
  Quite frequently, there are no words in cultures that describe depression as there is no literal meaning.
  In other cultures, eg Punjabi, a label of PND may have implications across the extended family and reduce the family status in the community. Using terminology such as ‘sadness’ not ‘depression’ may be more acceptable with Punjabi and other South Asian families.
• Lack of knowledge in the community about PND: this is often associated with difficulties in gaining the necessary care and the type of support needed to respond to women’s needs and will usually require capacity building at a local level.
• Quality of the translation of the EPDS: when the EPDS is translated from English into another language, great care is needed that each question and the EPDS as a whole has conceptual, ethical, functional and measurement equivalence as behaviours, attitudes, values, sentiments and words make sense and acquire meaning only within the context of the culture in which they are expressed.

Validation studies should show that the translated EPDS is sensitive for detecting depression against a translated and validated gold standard diagnostic instrument.