Arch Womens Ment Health DOI 10.1007/s00737-014-0486-8

ORIGINAL ARTICLE

Postnatal demoralisation among women admitted to a hospital mother-baby unit: validation of a psychometric measure I. Bobevski & H. Rowe & D. M. Clarke & D. P. McKenzie & J. Fisher

Received: 27 October 2014 / Accepted: 3 December 2014 # Springer-Verlag Wien 2014

Abstract Demoralisation is a psychological state characterised by experiences of distress and sadness, helplessness, subjective incompetence and hopelessness, in the context of a stressful situation. Experiences of demoralisation may be particularly relevant to women who have recently given birth, who can feel incompetent, isolated and helpless. The psychometric properties of the Demoralisation Scale among women in the postnatal period participating in a clinical program were examined. Women admitted with their infants to a hospital motherbaby unit in Australia for five nights were recruited consecutively (N =209) and assessed at admission and discharge. The Demoralisation Scale was perceived as relevant and exhibited high reliability, acceptable construct validity and good sensitivity to change. The mean demoralisation score was high (M=30.9, SD=15.5) and associated with negative experiences of motherhood and functional impairment, independent of depression and anxiety symptoms. Mean demoralisation decreased significantly after program completion (M=18.4, SD=12.4). More participants showed a significant improvement in demoralisation (57.5 %) than in depression (34.8 %) and

I. Bobevski (*) : H. Rowe : J. Fisher Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, 6th Floor, Alfred Centre, 99 Commercial Road, Prahran, Melbourne, Victoria 3004, Australia e-mail: [email protected] I. Bobevski : D. M. Clarke Department of Psychiatry, Southern Clinical School, Monash University, Melbourne, Australia D. P. McKenzie Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

anxiety (9.8 %) symptoms. Demoralisation can provide a useful framework for understanding and measuring the experiences of women participating in postnatal clinical programs and in directing treatment towards helping women to acquire the necessary caregiving skills and increasing parental efficacy. The Demoralisation Scale is a useful clinical tool for assessing intervention effects. Keywords Demoralisation . Postnatal mental health . Early parenting . Mother-baby units

Introduction Demoralisation is a psychological state occurring in stressful life situations where a person feels that he/she is unable to respond effectively to his/her circumstances. It is characterised by feelings of distress and sadness, helplessness, subjective incompetence and hopelessness (de Figueiredo 1983; Frank 1974). Demoralisation has been found to be distinct from the diminished ability to experience pleasure (anhedonia) that is an important hallmark of depression with melancholic features (Clarke et al. 2000, 2003, 2005; McKenzie et al. 2010; Weber 2000). Demoralisation is a dimensional phenomenon that is not part of a psychiatric diagnostic system. Some aspects of demoralisation overlap with the DSM-5 (American Psychiatric Association 2013) criteria for major depressive disorder. Sadness, hopelessness and feelings of worthlessness are included in the DSM-5 criteria but are not necessary or sufficient for diagnosis of depression. In addition, some characteristics of demoralisation (such as helplessness, hopelessness and worthlessness) often feature in dimensional scales of depression (Clarke 2011). However, current definitions and measures of depression rarely include subjective incompetence, a very important hallmark of demoralisation (de

I. Bobevski et al.

Figueiredo 2012), and do not take into account the context of a stressful situation. So far, demoralisation has predominantly been studied in medically ill populations, where it has been found to have an important and independent role in the will to live and has been useful in helping to formulate more effective psychosocial treatment strategies (Clarke et al. 2005; Mangelli et al. 2005; Marchesi and Maggini 2007; Rafanelli et al. 2005). Although, so far, demoralisation has not been examined in the postnatal period, experiences of demoralisation may be particularly relevant to women mothering young infants, who can feel incompetent, isolated and helpless. Early motherhood is physically and emotionally demanding (Small et al. 1994) with frequent experiences of severe fatigue (Rowe and Fisher 2010a). It has been compared to other life events with adjustment difficulties and experiences of loss, such as bereavement and physical illness (Oakley and Chamberlain 1981). Looking after an infant is a technically skilled task for which many women had not had the opportunity to yet acquire the skills (Rowe and Fisher 2010b), and especially so for mothers of unsettled infants (Beck 2002). Unsettled infant behaviour includes prolonged crying, frequent night waking and feeding difficulties. At least one in four families experience problematic infant crying and one in three experience problems with infant sleep over the first 12 months (Fisher et al. 2012). Unsettled infant behaviour is a strong risk factor for maternal depression through erosion of the mother’s feelings of competence as a caregiver (Cutrona and Troutman 1986). Furthermore, maternal self-efficacy is an important factor in maternal mental health (Jones and Prinz 2005). A study of women with unsettled infants admitted to an Australian hospital mother-baby unit (Fisher et al. 2002b) found that only a third of women experienced probable depression, another third experienced psychological distress below clinical levels and all experienced severe fatigue due to sleep deprivation. Although only a third of the women experienced clinically significant psychological symptoms, all had been assessed by medical practitioners as being in sufficiently high need of care to be referred for hospital admission. The traditional focus on symptoms of depression and anxiety might not adequately capture many of the difficulties that can be part of this life stage for many of these women. Current diagnostic frameworks of depression do not adequately take into account the psychosocial context of depressive symptoms and can neglect people’s experiences and thought processes (Clarke 2011). A valid measure of postnatal demoralisation, in addition to the traditional assessment of symptoms of depression and anxiety, may capture better women’s response to a stressful situation, thus contributing to a better understanding of their experiences and improved assessment and clinical interventions. A scale to measure demoralisation, the Demoralisation Scale, was constructed by Kissane et al. (2004), based on their

work with palliative care patients. The content and wording of the Demoralisation Scale appears to be appropriate and relevant to postnatal experiences. It measures dimensions of loss of meaning, dysphoria, disheartenment, helplessness and sense of failure. Aims This study aimed to examine the psychometric properties of the Demoralisation Scale (Kissane et al. 2004), including reliability, factor structure, perceived relevance and construct validity, among women in the postnatal period admitted to a hospital mother-baby unit.

Methods Setting The study was conducted in a mother-baby unit at a private hospital in Australia between July and December 2012. Australia is unique in offering such clinical residential early parenting services to assist women to manage unsettled infants and acquire caregiving skills (Fisher et al. 2011). The unit admits approximately 19 women and their babies every week for a 5-night stay. Women admitted for care to these services often experience complex mental health problems, reflecting adverse social circumstances and difficult reproductive events (Fisher et al. 2011). All women receiving care at these services are referred for hospital admission by medical practitioners. The women complete a structured residential program focusing on psychoeducation, parental skill building, problem solving and anxiety reduction through supported exposure to aspects of infant care that have been worrying. The program is led by a multidisciplinary team, including general practitioners, nurses, clinical psychologists and psychiatrists. Inclusion criteria All women admitted to the hospital unit during the recruitment period were eligible to participate in the study. Procedure All women who were admitted during the recruitment period were approached on their day of admission and given verbal and written information about the study and a pack containing the study’s consent forms and questionnaires. Participants completed the study materials both on admission and on discharge from the unit. Participants were also asked for consent to access their medical records to obtain their scores

Postnatal demoralisation among women admitted to mother-baby unit

on the Edinburgh Postnatal Depression Scale, which is completed as part of standard care at the unit on admission, so as not to burden them with completing it again. Measures Demographic information was collected about participants’ age, baby’s age, marital status, education and country of birth. The Demoralisation Scale (Kissane et al. 2004) is a 24-item scale which was developed and validated with palliative care patients. Scale items are listed in Table 1. Items are scored on a 5-point Likert scale from 0 “never” to 4 “all the time”. Total scores range from 0 to 96. Five factors were identified through exploratory factor analysis during the development of the scale: Loss of purpose and meaning, dysphoria, disheartenment, helplessness and sense of failure. We added a question at the end of the Demoralisation Scale to assess to what extent Table 1

women perceived the scale applicable to their present situation: “To what extent did the above questions seem applicable and relevant to your present situation?”, on a scale from 0 “not at all relevant” to 10 “extremely relevant”. The BaM-13 (Matthey 2011) is a 13-item scale measuring women’s experience of early motherhood, including interactions with and closeness to the child, confidence as a mother, feeling isolated and unsupported. A cutoff score of 9+ (in a range 0–39) indicates a high level of negative experiences of mothering. The Depression Anxiety Stress Scale (DASS-21) (Lovibond and Lovibond 1995) consists of three 7-item subscales with a range 0–21, measuring depression, anxiety and stress. Recommended cutoff points for moderate levels of depression, anxiety and stress are 14, 10 and 19, respectively, and for severe levels 21, 15 and 26 respectively.

Item characteristics and exploratory factor analysis of the Demoralisation Scale

Factor (% of total variance explained)

Item mean (SD)

Corrected item-total correlation

Factor loadings F1

F1: dysphoria/hopelessness (47.4 %) (α=0.91) 11. I feel irritable. 16. I am angry about a lot of things. 15. I tend to feel hurt easily. 21. I feel sad and miserable. 10. I feel guilty. 18. I feel distressed about what is happening to me. 5. I no longer feel emotionally in control. 9. I feel hopeless. 22. I feel discouraged about life. F2: helplessness (7.3 %) (α=0.88) 24. I feel trapped by what is happening to me. 23. I feel quite isolated or alone. 7. No one can help me. 4. My role in life has been lost. 8. I feel that I cannot help myself. 6. I am in good spirits. F3: loss of meaning (5.6 %) (α=0.81) 14. Life is no longer worth living. 20. I would rather not be alive. 2. My life seems to be pointless. 13. I have a lot of regret about my life. 3. There is no purpose to the activities in my life. F4: sense of failure (4.5 %) (α=0.81) 17. I am proud of my accomplishments. 19. I am a worthwhile person. 1. There is a lot of value in what I can offer others. 12. I cope fairly well with life.

2.3 (0.9) 1.6 (1.0) 1.7 (1.0) 1.4 (1.0) 1.9 (1.1) 1.7 (1.1) 1.8 (1.0) 1.2 (1.1) 1.0 (1.0)

0.58 0.67 0.68 0.73 0.58 0.70 0.72 0.79 0.77

0.72 0.72 0.70 0.68 0.66 0.63 0.59 0.59 0.55

1.4 (1.2) 1.5 (1.2) 1.3 (1.1) 1.0 (1.0) 1.2 (1.0) 1.6 (0.8)

0.76 0.68 0.63 0.65 0.76 0.72

0.52

0.2 (0.05) 0.1 (0.4) 0.6 (0.9) 1.1 (1.0) 0.7 (0.9)

0.55 0.38 0.69 0.58 0.61

1.6 (1.0) 1.3 (0.9) 1.5 (0.8) 1.5 (0.8)

0.58 0.60 0.56 0.65

Positively worded items (1, 6, 12, 17, 19) have been reverse scored

F2

F3

F4

0.66 0.66 0.61 0.60 0.54 0.48

0.53

0.80 0.78 0.67 0.61 0.56 0.78 0.77 0.72 0.50

I. Bobevski et al.

The Edinburgh Postnatal Depression Scale (EPDS) (Cox et al. 1987) is a 10-item scale assessing symptoms of depression, with a score range of 0–30. Scores of 10–12 indicate minor depression and 13+ indicates probable depression (Cox et al. 1987; Matthey et al. 2006). Functional impairment was assessed with two questions about full and partial days out of role (i.e. being unable to carry out normal daily responsibility because of emotional health) in the last 14 days, based on two similar questions in the Australian National Survey of Mental Health and Wellbeing 2007 (Australian Bureau of Statistics 2009). Functional impairment was only assessed on admission at the unit but not at discharge.

questionnaires on admission, a response rate of 66 % (209/ 317). Of the 209, 89 % (186/209) returned the questionnaires on discharge. Of the 209 participants, 187 (89.5 %) gave consent to obtain the EPDS from their hospital file, but for one participant the admission EPDS data was unavailable. There were no significant differences in demographic characteristics between participants with available and missing EPDS scores, although there was a non-significant trend for more participants from non-English speaking backgrounds to refuse consent compared to those with English speaking background (24.1 % versus 13.6 %, χ2 =2.1, p=0.144). Demographics

Analysis The internal reliability of the Demoralisation Scale was determined by calculating Cronbach’s alpha coefficients for the total scale and each subscale. The factor structure of the Demoralisation Scale was examined with exploratory factor analysis. Convergent validity was investigated by calculating Pearson’s correlation coefficients between the Demoralisation Scale and the other measures of distress. Discriminant validity was investigated by examining cross-tabulations of cutoff points (based on quartiles) of the Demoralisation Scale and the recommended cutoff scores of the depression and anxiety measures. As further evidence for discriminant validity, regressions and commonality analyses (Tabachnick and Fidell 2011) were carried out to examine whether demoralisation was related to the BaM-13 and to days out of role independently of depression and anxiety symptoms. Commonality analysis helps to determine the relative importance of each independent variable. All of the above analysis was carried out on the admission data only. Paired t tests were carried out and effect sizes (Cohen 1992) were calculated to measure the mean change in demoralisation compared to the other distress scales from admission to discharge. Change was further assessed by determining the proportion of women who showed reliable change (i.e. unlikely to be due to chance) in demoralisation scores from admission to discharge by calculating Reliable Change Indices (Jacobson et al. 1999; Jacobson and Truax 1991). The IBM SPSS 20.0 (IBM Corp. 2011) statistical package was used for all analysis, except for the regression analysis predicting days out of role, for which Stata 12.0 (StataCorp 2011) was used.

Participants’ mean age was 33.8 years (SD=5.2, range 22– 47 years). The babies’ age varied from 1 to 22 months (mean= 7.2, SD=3.7). Approximately half of the women were primiparous (54.1 %) and six (2.9 %) had twins. Participants were predominantly Australian born (75.1 %), with 14.8 % born in non-English speaking countries. Nearly all women were partnered (97.6 %). The proportion of tertiary educated women (69.9 %) was high. This demographic composition is typical for women admitted to similar services in Australia (Fisher et al. 2002a). Mean scores on admission The mean score of the Demoralisation Scale was 31.2 (SD= 15.7). There were no large or significant mean differences in mean demoralisation between any of the demographic groups described earlier. Mean depression scores (Table 2) were in the minor depression range on the EPDS and in the mild range on the DASS-21 depression scale. The proportion of women scoring within the probable major depression range on the EPDS was 33.9 %. Mean anxiety was in the normal range and stress in the moderate range on the DASS-21. Reliability The Demoralisation Scale had a high internal consistency (Cronbach’s alpha=0.95). Corrected item-total correlations (Table 1) ranged from 0.55 to 0.79, except for item 20 (“I would rather not be alive”) which had a lower correlation with the rest of the scale of 0.38. Factor structure

Results During the recruitment period, 317 women were admitted to the unit. All of them were approached and invited to participate in the study. Of these, 209 completed the study

Four factors (dysphoria/hopelessness, helplessness, loss of meaning and sense of failure) were extracted, using the principal components extraction method and a Varimax rotation (Child 2006), with eigenvalues>=1 and based on the scree

Postnatal demoralisation among women admitted to mother-baby unit Table 2

Correlation matrix of the subscales of the Demoralisation Scale and other measures of distress and experiences of motherhood F1

F1: dysphoria/hopelessness (mean of items=1.62, SD=1.04) F2: isolation and helplessness (mean of items=1.35, SD=1.04) F3: loss of meaning (mean of items=0.54, SD=0.77) F4: sense of failure (mean of items=1.48, SD=0.89) Total demoralisation scale score

F2

F3

F4

EPDS (M=10.8, SD=4.7)

DASS-Depression DASS-Anxiety (M=9.7, SD=9.0) (M=7.0, SD=7.6)

DASS-Stress (M=20.0, SD=9.4)

BaM-13 (M=16.2, SD=6.4)



0.69*

0.75*

0.49*

0.66*

0.72*

0.82* –

0.68*

0.79*

0.51*

0.62*

0.74*

0.64* 0.65* –

0.51*

0.69*

0.42*

0.46*

0.58*

0.64* 0.68* 0.57* –

0.59*

0.66*

0.47*

0.48*

0.67*

0.94* 0.93* 0.78* 0.79* 0.72*

0.83*

0.54*

0.66*

0.79*

*p

Postnatal demoralisation among women admitted to a hospital mother-baby unit: validation of a psychometric measure.

Demoralisation is a psychological state characterised by experiences of distress and sadness, helplessness, subjective incompetence and hopelessness, ...
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