Postpartum Depression in China Equivalent to Rate in West

A new study suggests that postpartum depression is quite common among women in Hong Kong—about one in every 10 women who bear a baby falls prey to it. This rate is comparable to that in Western societies.

The study was conducted by psychiatrist Dominic T.S. Lee, M.D., and colleagues in the psychiatry and obstetrics departments of the Chinese University of Hong Kong and in the social medicine department of Harvard Medical School.

The study is reported in the February American Journal of Psychiatry.

Lee and his team recruited for their study 959 pregnant women who visited the antenatal clinic of a Hong Kong university hospital. This hospital serves a population of 1 million people from diverse socioeconomic backgrounds, and all women who want to deliver their babies at this hospital have to go through the clinic. Assistants to Lee and his colleagues collected sociodemographic, medical, obstetrical, and psychiatric data from the subjects.

Three months after the women had delivered their babies, 781 (81 percent) of them were available to fill out the 12-item General Health Questionnaire—a self-report rating scale commonly used to screen for psychiatric problems.

Ninety-six (12 percent) of these women obtained high scores, that is, seemed to be depressed. These 12 percent were then further assessed by the study team to better identify who were truly suffering from depression. For this purpose, team members used the nonpatient version of the Structured Clinical Interview for DSM-III-R (SCID).

While the SCID uses a semistructured interview format that poses direct questions, such as “Are you depressed?,” it also allows the interviewer to ask additional, culturally specific questions that might be necessary to obtain accurate results. And in this case, the researchers asked subjects whether they might be experiencing “wind illness” or “wind inside the head.”

In other words, a traditional belief among Chinese women is that during the first month after childbirth they should avoid going outside and being exposed to drafts, and that failure to comply with this restriction can cause “wind” to enter the body and harm health. What’s more, Chinese women, like their counterparts in many Western countries, commonly use somatic complaints to express emotional distress. And mental illness is heavily stigmatized in Chinese society. Thus, if a subject told an interviewer that she was experiencing “wind illness” or “wind inside the head,” the interviewer might interpret it to mean that she was depressed, even if she had not admitted to being so when directly asked.

Three months after giving birth, about 6 percent of subjects were found to have major depression, and some 5 percent qualified for a diagnosis of minor depression. Thus 11 percent of the subjects were depressed to some extent. Studies of postpartum depression in Western societies have found a 7 percent prevalence rate for major depression and an 11 percent prevalence for major and minor depression together.

Thus, their study results, Lee and his coworkers indicated, “suggest that the rate of depression among Chinese women is not different from the rates found among women of childbearing age in Western society” and that “postpartum depression is common among contemporary Chinese women.”

The immediate implication of this study, the researchers asserted, is “that one in 10 contemporary Hong Kong women in the postpartum period suffers from depressive disorders,” and that Hong Kong obstetricians and psychiatrists need to be aware of this fact and provide a universal screening program to diagnose depression in postpartum women.

Such a screening program is urgent, they explain, since many women who succumb to postpartum depression have not been depressed before and may misconstrue their mental illness as simply maladjustment to sleep deprivation, childbearing, and parenthood. And such a screening program is pressing, they add, since postpartum depression can so impair new mothers that they fail to interact with their babies, and as a result the babies do not develop normally.

Another implication of their study, the investigators pointed out, is that postpartum depression may be as ubiquitous in other parts of China as it is in Hong Kong, although current evidence regarding this point is in question. Specifically, the six studies that have been conducted on postpartum depression in areas of China other than Hong Kong only used the Edinburgh Postnatal Depression Scale, a self-report screening scale for postpartum depression, and results indicating depression rates ranged from 0 percent to 18 percent.

And yet a third implication of their study, the researchers believe, is that it may mirror what is happening in China in general as far as depression is concerned.

Back during the 1980s, for instance, population studies implied that depression was rare among the Chinese. But then in 1998, an epidemiological study conducted by Jinrong Wang, M.D., a psychiatrist with the Third Hospital of Daqing in Heilongjiang, China, suggested that depression among the Chinese is becoming more commonplace.

Wang’s study concerned seven areas of China, including Beijing, Hunan, Nanjing, and Shanghai. The rise in depression was found to be most prominent in cities. The study by Lee and his colleagues pointed to a similar trend. “Our data suggest that depression may no longer be rare in the Chinese population,” Lee and his team asserted.

So, if depression was truly scarce in China a few years ago, but is now much more widespread, why has this change taken place? The reason, according to Lee and his coworkers, is that Chinese society has become much more Westernized than it used to be.

“Traditional values and sociocultural factors, such as family cohesiveness, a low divorce rate, and parental substitutes, have often been cited to explain the low rates of all depression in Chinese studies from the 1980s,” Lee and his team noted. “However, these putative protective factors may no longer be relevant, as we have seen divorce, family violence, job insecurity, child and sexual abuse, juvenile pregnancy, deterioration in network solidarity, and alcohol and drug addiction [invade Chinese life].”

“Surprisingly, few researchers have studied the presentation and symptomatology of depression in the Chinese population before,” Lee told Psychiatric News. As a result he, along with Arthur Kleinman, M.D., of Harvard Medical School, and Cui Ma, M.D., of Chinese Zhongzhan Medical University, are conducting a series of investigations in southern China to do so.

The study, “A Psychiatric Epidemiological Study of Postpartum Chinese Women,” is posted on the journal’s Web site at www.ajp.psychiatryonline under the February issue. ▪