Nature of depression in Chinese populations within and outside of pregnancy: a study in Inner Mongolia
Cheung, Ho Nam
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Depression poses a global threat for mental health (Murray & Lopez, 1996). However, in China, national studies of depression epidemiology are very few. Only from 2011 have Chinese researchers began to adopt internationally recognized diagnostic criteria and standardized interview instruments in psychiatric epidemiological surveys (Guo et al., 2011), and previous studies generated inconsistent results of depressive prevalence. As the largest ethnic group in the world, the Chinese account for 18.9% of the world’s population (National Bureau of Statistics of China, 2015). Yet most research on depression is based on Western samples and may not accurately characterize depression as experienced by Chinese populations. This thesis examines depression in non-pregnant and pregnant women in Inner Mongolia, who are under the influence of cultural values of collectivism and social factors specific to China. Chinese society adheres firmly to traditional values (Whyte, 2005), while market reform, birth-control policy, together with high parental investment in childcare and rearing construct a unique and sometimes unfavorable environment for Chinese women that may influence their depression expression. This thesis includes a series of three linked studies. The first study validated the 52- item New Multidimensional Depression Scale (MDAS) with clinically depressed individuals in Inner Mongolia. The aims were to assess whether the MDAS demonstrated good psychometric properties in clinically depressed Chinese patients for the scale to be factor analysed on a Chinese construct of depression symptomatology to show cultural characteristics in China. This aim was achieved by carrying out Exploratory and Confirmatory factor analysis in separate studies. One hundred and seventy-one clinically depressed participants were recruited in Inner Mongolia. They were given the MDAS and Beck Depressive Inventory (BDI) and other scales to complete. The psychometric properties of the MDAS were tested regarding reliability and validity. Following which an Exploratory factor analysis (EFA) was run on MDAS. Several findings emerged in the study. First, the first factor extracted comprised of core psychological and affective symptoms conceptualized in the Western construct of depression. An interpersonal-cognitive factor was extracted as the second factor, followed by a third somatic factor in the cluster of symptoms. The results suggested that core affective and cognitive symptoms for diagnosis are universal across cultures, while Chinese individuals express interpersonal symptoms that characterized their collectivistic culture that emphasizes interpersonal harmony. Study 2 examined depressive symptoms in the antenatal period in Inner Mongolia women. Two-hundred and thirty-four women, mostly in their third trimester, were recruited in an antenatal hospital in Inner Mongolia. They completed the MDAS, Beck Depression Inventory (BDI) and Edinburgh Postpartum Depression Scale (EPDS). In exploring how depression in its item content is expressed and experienced by pregnant Chinese women, the study also searched for the best-fit model of MDAS on pregnant women in Inner Mongolia. It compared three factor models: the three-factor structure of MDAS from study 1, the hypothesized four-factor model corresponding to each subscale (emotional, cognitive, somatic and interpersonal), and the one-factor model corresponding to a unidimensional structure of the MDAS. A best-fit model was found for the four-factor model, supporting using the four hypothesized subscales of MDAS on pregnant women. In a subsequent step, the MDAS was validated and its psychometric properties were tested to show illustrated results. The findings supported measuring interpersonal symptoms in self-report measurements to measure different aspects of depressive severity in Chinese pregnant women. In particular, somatic symptoms should be considered with caution in screening and primary care. The finding has significant implications for assessing with self-report questionnaires, which are widely used in clinical settings. Study 3 was based on the same sample as study 2 and investigated risk factors associated with antenatal depression in China. China has undergone drastic socio-economic and political transformation in the last twenty years. Unfortunately, market reform is creating less favourable employment conditions, and the traditional value of male dominance still stands firmly in the society. Women are facing more financial insecurity and a tight birth control policy and growing stress in work-and-family balance. All these create an environment that could contribute to their depression that could be expressed in a different way from Western populations. Depression may also be underlined by different risk factors related to the social and cultural environment. This study measured demographic characteristics (including age, education, employment, week of gestation, first pregnancy), social support, social activity, work stress, and work-family balance and their relationship with depression. It included three parts. In part 1 participants were classified into depressed and non-depressed groups using EPDS>10 as the cut-off point for depression. The two groups were compared on demographic variables using the Chi-square test and on psychosocial risk factors using the Mann-Whitney U test. No significant demographic variable was found to distinguish the two groups, whereas self-esteem, work stress and social activities differed significant between depressed and non-depressed pregnant women. Bivariate correlations between psychosocial risk factors and depressive scales (MDAS, BDI and EPDS) gave rise to significant correlations between risk factors and each scale. In the third part hierarchical multiple linear regression analysis examined associations between social and demographic risk factors and depression. The results showed that work stress, work-and-family balance, social activity and social support were significantly associated with depressive severity in overall severity of depression (total MDAS score) and each domain of depressive severity (each subscale of MDAS). In conclusion, the three studies together provide novel insight into our understanding of depression within and outside of pregnancy in Chinese women, in terms of symptoms and risk factors. The Western conceptualization of depression possesses great validity across cultures, that the core symptoms of depression remain universal for diagnosis. Chinese cultural values and social environment are reflected in the cultural expressions of depressive symptoms especially in depressed individuals but less affective in pregnant women. As hypothesized, Chinese society influenced risk factors related to education and work-family balance in pregnant women. The result supported using a scale with a comprehensive interpersonal symptom checklist because it potentially captures Chinese expression and experience, which could be characterized by an interpersonal style of illness presentation. In addition, the best-fit four-factor model supported including interpersonal symptoms in self-report measures and they are also related to different risk factors from other domains of depressive symptoms. This could be linked to some unfavourable social and cultural influence pregnant Chinese women experience. The thesis gives rise to implications for potential clinical applications. The advancement of cultural characteristics in symptom contents in both clinical and pregnant population facilitates a better symptom checklist for assessing depression severity. In particular, it helps to modify existing self-report questionnaires with culturally sensitive symptoms for better discrimination of individuals.