The EPiC Study
Does poor emotional processing predict the
development of postnatal depression?
Findings from the Emotional Processing in Childbirth Study
DCP Annual Conference, 3rd December 2015. London.
Dr. Carol Wilkins, Lead Midwife for Education.
Faculty of Health and Social Sciences, Bournemouth University.
Professor Roger Baker, Bournemouth University
Professor Debra Bick, Kings College, London
Professor Peter Thomas, Bournemouth University
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Emotions in pregnancy
• Childbirth continuum -engenders complex range
of positive and negative emotions
• Emotions triggered by
• changes in role/lifestyle
• physical and psychological pregnancy specific stimuli
• ‘normal’ life stressors
• Yet no studies have explored how the
management of these emotions impacts on
perinatal mental health
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Predicting PND
Postnatal depression (PND) – serious public health concern
impacting on whole family
3 meta-analyses comprising 100 international studies
(approx 24,00 women) (O'Hara and Swain 1996; Beck 2001; Robertson et al.
2004). have identified the strongest predictors of postnatal
depression as being :
• Strong - depressed mood antenatally, history of
depression, perceived low levels of social support, life
stresses
• Medium - low self-esteem and poor marital relationship
• Low - socioeconomic status and obstetric factors
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What is Emotional Processing?
• Emotional Processing (EP) describes the way
people deal with the feelings/emotions caused
by stressful events in their lives.
• Effective EP is achieved when emotions are
processed in such a way that they do not impact
on a person’s ability to continue with their
everyday lives (Rachman 2001).
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Aims of study
• To investigate the possibility of predicting
postnatal depression from scores on the
Emotional Processing Scale (in conjunction with
other identified risk factors for postnatal depression).
• To examine the relationship between emotional
processing in pregnancy and the development of
postnatal depression (in conjunction with other identified risk
factors for postnatal depression)
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Methods
• Approach - Prospective longitudinal cohort study
• Setting/ recruitment– Hospital Trust in the South of England
• Participants - Cohort of 974 pregnant women, aged 16 to 44 – recruited
at first antenatal screening appointment at 13 weeks (between Nov. 2007
and Feb. 2009)
• Data collection – Questionnaires given personally at 13 weeks and
postal questionnaires sent at 34 weeks gestation and 6 weeks
postpartum.
• Outcome measures – validated tools - EPS, EPDS, SF-36, RSE
• Data analysis - SPSS version 16 – independent samples t-test, one way
ANOVA, repeated measures ANOVA, multiple and binary logistic
regression modelling
• Ethics – Approval from Local Research Ethics Committee and clinical
governance department of hospital Trust
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Questionnaires
• EPS
25-item self-report scale
• Edinburgh Postnatal Depression
Scale (EPDS)¹
10-item self-report scale .
• Short Form-36 (SF 36)²
36-item generic measure of 8
domains of positive and negative
physical and mental health.
• Rosenberg Self-Esteem Scale (RSE)³
10-item self-report scale
• Practical and emotional support
• Life stresses
….perceived from partners, family,
friends
…..during the last year
¹Cox et al.1987, ²Ware and Sherbourne 1992, ³Rosenberg 1989
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Questionnaires
• Questionnaire 1:
• Demographics - age, occupation, parity, marital status, ethnicity,
past/current psychiatric history, family mental health history,
current medical history
• Questionnaire 2:
• Health during pregnancy, GP or hospital in-patient treatment
• Questionnaire 3:
• Birth experiences and care, feeding choices, postnatal health
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The EPiC Study
FINDINGS
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Response rates
Questionnaire 1:
•1333 women agreed to
participate
•974 women completed and
returned Q1- sample
Questionnaire 2:
•75% (n=713) responded
•23% non-return (n=243)
(remained in study)
•2% withdrawn
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Questionnaire 3:
• 57% (n=554) of original
cohort responded
• 876 distributed
• 63% returned
• 53% (n=520) returned all
three questionnaires
completed
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Demographics
Variable
Number
%
Primiparous
460
47.6
Multiparous
506
52.3
19 and under
49
5.1
20-24
117
12.1
25-29
260
26.9
30-34
304
31.5
35 and over
235
24.3
Has partner
947
98.0
No partner
19
2.0
Relationship with
Good
937
99.5
partner
Not good
5
0.5
Partner
876
90.7
Alone
37
3.8
Parents or relation
52
5.3
Divorce
23
2.3
Stressful life events
Death of loved one
163
16.9
in preceding 12
Moved house
286
29.6
221
22.9
Parity
Age
Partner
Lives with…..
months
www.bournemouth.ac.ukNew job
Total responses
966
965
966
942
965
963
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Socioeconomic status
Occupation
Number
Higher managerial/professional (e.g. doctors, lawyers, dentists)
22
Lower managerial (e.g. teachers, nurses, journalists)
149
15.6
Intermediate occupations (e.g. health care assistants, secretaries)
219
22.9
Small employers (e.g. hairdressers)
22
2.3
Lower supervisory and technical (e.g. supervisors, foreman)
130
13.5
Semi-routine (e.g. shop assistant, call centre workers, care assistants)
142
14.8
Routine (e.g. waitresses, cleaners, bus drivers)
49
5.1
Never worked, long term unemployed
21
204
2.2
21.3
958
100
Not classified ( incl. students, housewives,
Total
Missing information
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insufficient information)
%
2.3
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EP in pregnancy and postpartum
• Mean EPS scores improved over time – statistically significant. (2.72;
2.62; 2.38)
• Greatest increase in scores (worsening of EP) between early and late
pregnancy (22.7%). Greatest decrease (improvement in EP) between
early pregnancy and postpartum (24.7%).
• Significantly higher EPS scores in pregnancy found in:
•
•
•
•
Younger maternal age groups (19 years and under, 20-24 years)
Those with past mental health history
Those with current mental health problems
Those without a partner
• Higher pregnancy and postpartum EPS scores found in:
• Multiparous women with a history of postnatal depression
• Family history of depression
• Parity, physical health and SES made no significant difference to EP
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Relationship between poor EP and
likelihood of postnatal depression
•
•
•
Significantly high positive correlations between EPS and EPDS at each time
point (p<0.001)
Strong positive correlations between EPS 1 scores and EPDS 3 and between
EPS 2 and EPDS 3
Significant difference of 1.8 in mean EPS 1 scores between women who scored
above (n= 76) and below (n=468) threshold in EPDS 3. (95% CI 1.4 to 2.2, t-9.5,
p<0.001)
EPDS and EPS scores dichotomised into high and low:
• Significant difference of 2.2 in mean EPS 2 scores between those scoring high
(n= 72) and low (n= 453) on the EPDS 3. (95% CI 1.8 to 2.6, t -10.6, p<0.001)
• 40% of women(n=30) with high EPS 1 scores had correspondingly high EPDS
3 scores, compared with 10% (n = 46) of women with low EPS 1 scores who
had correspondingly high EPDS 3 scores
• 50% of women with high EPS 2 scores (n=80) had correspondingly high
EPDS 3 scores.
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Prediction of PND in early pregnancy
Multiple regression modelling performed:
Model 1: Four modifiable early pregnancy variables made a contribution to
prediction of depression:
•EPDS 1 strongest (β = 0.21, t=3.08, p = 0.002, 95% CI 0.36 to 2.34)
•EPS 1 next strongest (β = 0.19, t = 3.13, p = 0.002, 95% CI 0.07 to 0.33)
•Past history of depression
•Physical wellbeing in early pregnancy
Model 2: adding variables associated with birth experience…..
•Significant contributions to prediction of PND in order of strength – EPDS
1, EPS 1, satisfaction with birth experience, feeding difficulties, past history
of depression, physical wellbeing.
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Prediction of PND in early pregnancy
After adjusting for all other risk factors for PND regression
modelling predicted that:
• for every 1 unit increase in EPS 1 scores there would
be an average increase of 0.2 in mean EPDS 3
scores (p = 0.002, B = 0.6)
With variables associated with the birth experience added
regression modelling predicted that:
• for every increase of 1 unit in EPS 1 scores there
would be an average increase of 0.6 in mean EPDS 3
scores (p = 0.001, B= 0.58)
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Prediction of PND in late pregnancy
6 late pregnancy variables made a contribution to the prediction of PND:
•EPS 2 strongest predictor (β = 0.29, t = 5.08, p <0.001, 95% CI 0.5 to 1.13)
•Poor self esteem
•Poor practical support from partner
•Poor mental wellbeing (MCS 2)
•New job
•Moving house
For every 1 unit increase in EPS 2 scores there would be a predicted
average increase of 0.8 in mean EPDS 3 scores (p <0.001, B = 0.82)
BUT – if depression added to model only partner support remained
significant with late pregnancy depression the strongest predictor
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Prediction of PND from EPS sub-scales
In early pregnancy -2 sub-scale variables made statistically
significant contribution to prediction of EPDS 3 scores:
•Unregulated emotions - strongest (β = 0.17, t=2.7, p=0.0007, 95%
CI 0.1to 0.8)
•Suppression (β=0.13, t=2.16, p = 0.31, 95%CI0.03 to 0.61)
Late pregnancy – 2 sub-scale variables made statistically
significant contribution to prediction of EPDS 3 scores
•Unprocessed emotions - strongest (β=0.22, t=2.9, p=0.003, 95% CI
0.2 to 0.8)
•Unregulated emotions (β =0.18, t=2.6, p=0.009, 95% CI 0.1 to 8.2)
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Odds of high EPS 1 scores
predicting high EPDS 3 scores
3 early pregnancy variables made a significant contribution to prediction
of PND:
•High EPS 1 scores
•Poor physical wellbeing
•Low self-esteem
With birth experiences added – dissatisfaction with birth experience
became strongest predictor and feeding problems was also significant
predictor
After adjusting for other significant variables the odds of women with
high EPS scores in early pregnancy developing PND were 2.7 times
greater than women with low EPS scores. (Exp(B) = 2.7, 95% CI 1.4 to 5.3, p =
0.004). Sensitivity 20%; specificity 99%; ppv 68%.
BUT – EPS 1 no longer predictive when EPDS 1 added to model
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Odds of high EPS 2 scores
predicting high EPDS 3 scores
Only 2 late pregnancy variables made a significant contribution to
prediction of PND:
• High mean EPS 2
• High mean EPDS 2 scores
With birth experiences added EP became strongest predictor followed
by dissatisfaction with birth experience and depression in late
pregnancy
After adjusting for effects of variables in late pregnancy the odds of
women with high EPS scores in late pregnancy developing PND
were 6 times greater than women with low EPS scores (Exp (B) = 6.1,
95% CI 2.9 to 12.9, p <0.001).
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Summary of findings
• After adjusting for other variables identified as risk factors for PND,
poor EP in early and late pregnancy significantly predicted the
likelihood of PND
• The odds of developing PND were 2.7 times greater in women with
high EPS 1 scores than in those with low EPS 1 scores (in the
absence of antenatal depression in early pregnancy)
• The odds of developing PND were 6 times greater in women with
high EPS 2 scores than in women with low EPS 2 scores (even with
antenatal depression in late pregnancy)
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Implications for practice
Understanding EP in pregnancy and its interaction with
other recognised risk factors is valuable in planning
appropriate support for perinatal emotional health needs
•Reduction in postnatal care in UK – less opportunity to support emotional
difficulties. Pregnancy is ideal time to assess women’s EP and initiate
timely support which might subsequently reduce the risks of postnatal
depression.
•Need to explore resource effective ways to integrate a supportive structure
of emotion management into existing and proposed framework of antenatal
care
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Further research
•RCTs to explore whether intervention strategies to manage
EP antenatally can be successful in reducing the incidence
of depression.
•Exploration of whether EPS as a screening intervention
would prove socially, psychologically and economically
effective and safe for the population of pregnant women in
the UK – necessary to meet the rigorous criteria laid down
by the UK National Screening Committee
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Thank you
[email protected]
Tel: 01202 968317
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References and additional reading
Baker, R., Thomas, S., Thomas, P. W., and Owens, M., 2007. Development of an emotional
processing scale. Journal of Psychosomatic Research, 62 (2), 167-178.
Baker, R., Thomas, S., Thomas, P. W., Gower, P., Santonastaso, M., and Whittlesea, A.,
2010. The emotional processing scale: Scale refinement and abridgement (EPS-25).
Journal of Psychosomatic Research, 68 (1), 83-88.
Beck, C., 2001. Predictors of postpartum depression. Nursing Research, 50 (5), 275-284.
Cox, J. L., Holden, J. M., and Sagovsky, R., 1987. Detection of postnatal depression.
Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of
Psychiatry, 150, 782-786.
Da Costa, D., Larouche, J., Dritsa, M., and Brender, W., 1999. Variations in stress levels
over the course of pregnancy: Factors associated with elevated hassles, state anxiety and
pregnancy-specific stress. Journal of Psychosomatic Research, 47 (6), 609-621.
DiPietro, J. A., Ghera, M. M., Costigan, K., and Hawkins, M., 2004. Measuring the ups and
downs of pregnancy stress. Journal of Psychosomatic Obstetrics and Gynecology, 25 (3/4),
189-201.
Lobel, M., Cannella, D. L., Graham, J. E., Devincent, C., Schneider, J., and Meyer, B. A.,
2008. Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health
Psychology, 27 (5), 604-615.
Lothian, S. 2002. Emotional processing deficits in colorectal cancer : A theoretical overview
and empirical investigation. Thesis (PhD). Southampton: University of Southampton.
www.bournemouth.ac.uk
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References and additional reading
National Institute for Health and Clinical Excellence. 2007. Antenatal and postnatal mental
health: Clinical management and service guidelines. NICE clinical guideline 45. London:
National Institute for Health and Clinical Excellence.
O’Hara, M. W., and Swain, A. M., 1996. Rates and risk of postpartum depression: A metaanalysis. International Review of Psychiatry, 8 (1), 37.
Rachman, S., 2001. Emotional processing, with special reference to post-traumatic stress
disorder. International Review of Psychiatry, 13 (3), 164-171.
Raleigh, J., 2004. A preliminary comparative study of emotional processing in women with
fybromyalgia syndrome, rheumatoid arthritis and healthy subjects. Thesis (MSc). University
of Southampton .
Robertson, E., Grace, S., Wallington, T., and Stewart, D. E., 2004. Antenatal risk factors for
postpartum depression: A synthesis of recent literature. General Hospital Psychiatry, 26 (4),
289-295.
Rosenberg, M., 1989. Society and the adolescent self-image. Revised Edition ed.
Middeltown, CT.: Wesleyan University Press.
Ware, J., E, and Sherbourne, C., D. 1992. The MOS 36-item Short-Form Health Survey (SF36). 1. Conceptual framework and item selection. Medical Care, 30 (6), 473-483.
Wilkins, C. 2012. Emotional Processing in Childbirth. A longitudinal study of women’s
management of emotions during pregnancy and the association with postnatal depression.
Thesis (PhD) Bournemouth University
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