Abstract
Objective. To identify factors associated with depressive symptoms in inner-city mothers of young children.
Design. A cross-sectional survey was administered to a convenience sample of English-speaking mothers attending a well-child visit for a child aged 6 months to 3 years in a hospital-based, inner-city, general pediatric clinic. The maternal interview collected data on sociodemographic characteristics, and mothers' health and financial status. Mothers completed the Psychiatric Symptom Index (PSI), a 29-item checklist shown to have very good validity and reliability in a multicultural population. A total score of ≥20 represents high levels of symptoms; scores ≥30 strongly suggest major depression.
Results. Two hundred seventy-nine mothers completed the PSI. Mothers ranged in age from 14 to 48 years (mean, 27 years). Seventy-one percent were unmarried; 57% received public assistance. Forty-two percent of mothers were Hispanic, 40% black, 9% white, and 10% mixed or other races. Forty-eight percent were foreign-born. Twenty-four percent reported having a medical condition; 6% had activity limitation because of illness. The mean PSI score was 19; 18% of mothers had a PSI score ≥30 and 39% scored ≥20. PSI scores did not vary by age, race, birthplace, educational level, employment, marital status, or family composition. PSI scores were higher for mothers receiving public assistance (21 vs 17), with self-reports of poor or fair financial status (22 vs 15) and poor health status (52 vs 17). Mothers with activity limitations because of illness had significantly higher PSI scores (34 vs 18). Multiple regression analyses confirmed the independent relationships of these maternal characteristics to high PSI scores.
Conclusions. Depressive symptoms in inner-city mothers of young children are common. In this population of women with many risk factors, traditional sociodemographic risk factors did not successfully identify those who are depressed. However, mothers' self-reports of poor financial status, health status, or activity limitation because of illness were associated with higher levels of depressive symptoms. These findings may assist clinicians in distinguishing which mothers are likely to be depressed when almost all are at high risk.
Depression and depressive disorders are among the most prevalent mental health problems in the United States.1,,2 Between 2% and 8% of patients in primary care settings have major depression, according to studies based on screening tools and structured psychiatric interviews.3,,4Women have higher rates of depressive symptoms than men in both population-based1 and clinically-based studies.5 This increased risk among women persists across cultures, races, and socioeconomic levels.6
Being the mother of young children places a woman at particular risk for depression and depressive symptoms.5,7–11 Maternal depression has been found in a variety of pediatric practice settings at rates of 12% to 47%7,,8,10,12,13 and is exacerbated by having either several young children or a child with a chronic illness in the household.10,,11,14 Other risk factors known to increase vulnerability for depressive symptoms include inner-city residence, poverty and low socioeconomic status, unemployment, and lower levels of education.15–19
Despite the high prevalence, depressive symptoms in women are often unrecognized and untreated.20–27 As a result, women can experience significant psychologic, social, and occupational disability.28–31 Depressive symptoms in mothers of young children also place children at risk for developmental, behavioral, and emotional problems.32–36 Therefore, it is important for pediatricians and other pediatric health care providers to recognize mothers with depressive symptoms and children at risk.
Maternal depression is associated with a number of negative consequences for children of all ages. Punitive attitudes toward child rearing,37,,38 inaccurate knowledge of child development,13 and more negative, unsupportive, or intrusive parent-child interactions39 have been noted in mothers with depressive symptoms. Field et al40 found that infants of depressed mothers as young as 3 months of age were less responsive in interactions with both their own mothers and nondepressed strangers. Preschool children have also shown increased behavioral problems such as hostility and anxiety at home and at school41 and deviant cognitive and linguistic development.42 In a group of preschool children of inner-city minority adolescent mothers, Leadbeater and Bishop43 found a strong association between maternal depressive symptoms and child behavioral problems. Finally, older children and adolescents of depressed mothers are more likely to experience depression, substance abuse, and conduct disorder during their adolescence than children in comparison samples.34–3644–46
Given the negative consequences of depressive symptoms for both mothers and their children, pediatricians need to be able to recognize maternal depression. A particular problem exists in applying traditional risk factors to certain high-risk populations in which these risk factors may be almost universal. In this study, we explored rates of depressive symptoms in such a high-risk group of women—inner-city mothers of young children. Most women in this group have characteristics known to be associated with high rates of depressive symptoms; therefore, well-known, traditional risk factors may not be useful to identify those mothers at risk. We sought, therefore, to identify maternal characteristics associated with high levels of depressive symptoms within this already high-risk sample of women.
METHODS
Study Design
A cross-sectional survey that included both a maternal interview and a self-report checklist of psychiatric symptoms was conducted during the months of June through August in both 1995 and 1996. The study was conducted at a hospital-based, inner-city, general pediatric clinic that has ∼30 000 primary care visits per year. English-speaking mothers were eligible to participate in the study if they were the biologic mothers of children aged 6 months to 3 years who were attending a well-child health visit. Mothers of children of this age group were selected because they come frequently for preventive health care for their children, and have been the group previously studied by other investigators.7–11 The well-child visit was selected to minimize any potential maternal distress that may be associated with coping with an acutely ill child. Furthermore, mothers of acutely ill children may be distracted and concerned primarily with relief for their ill child, and may not cooperate as attentively as mothers whose children are well. Mothers were approached by trained interviewers while waiting to see their child's pediatric health care provider and asked to participate in the study, which was approved by the Institutional Review Board. Informed consent was obtained following the guidelines of our institution. This study did not examine mothers with primary languages other than English; however, previous authors have shown that rates of depressive symptoms in other cultural groups such as Hispanic women may be even higher.47,,48
Measures
The maternal interview included questions about sociodemographic characteristics, mother's health, and financial status. Sociodemographic characteristics ascertained included age, marital status, ethnic background, languages spoken, birthplace, educational level, employment and income status, and household composition. To determine health status, mothers were asked whether they had any ongoing health conditions or any activity they could not do because of their health. In addition, they were asked to compare their health with other people their age on a 5-point scale (excellent to poor). Mothers also were asked to describe their financial situation on a 5-point scale (very good to very poor). Finally, mothers were asked a global question about their happiness.
Mothers self-completed the Psychiatric Symptom Index (PSI),49 a 29-item scale that was developed on a community sample of 2299 men and women. The PSI provides a total symptom score as well as subscale scores on four dimensions (depression, anxiety, anger, and cognitive disturbance). Internal consistency, reliability, and concurrent validity have been well established.49 The item content of the PSI has been compared with two narrow-band instruments for depression and anxiety, the Center for Epidemiologic Studies Depression Scale (CES-D)50 and the State-Trait Anxiety Inventory,51 and was found to have comparable content validity to these instruments in meeting a majority of the Diagnostic and Statistical Manual of the American Psychiatric Association-IV (DSM-IV) criteria for major depressive disorder and generalized anxiety disorder.52
The PSI has been found to be valid and reliable in a multiethnic, disadvantaged, urban population.53 Cross-cultural reliability of the PSI has been tested on the subscales separately and on the total score in Puerto Rican and African-American mothers of inner-city populations.54 Other studies have also used the PSI successfully with urban, minority populations, including mothers of ill children.55
The PSI contains items that measure the frequency of symptoms experienced during the past 2 weeks from “never” to “very often.” Examples include: “How often did you … have trouble concentrating, notice your hands trembling, feel fearful or afraid, or feel downhearted or blue?” PSI items are scored using a 4-point scale (0 to 3) with the total score and subscales calculated as a percentage of the total possible score. A total score of ≥20 represents high levels of symptoms.49 Scores ≥30 strongly suggest major depression; Bauman56 found a sensitivity of 90% and specificity of 58% against the section on Major Depression within the Diagnostic Interview Schedule57 using this cutoff.
Data Analysis
The relationships of mothers' PSI total scores to sociodemographic characteristics, health status ratings, financial status ratings, and global assessments were examined using one-way analysis of variance with Student-Newman-Keuls tests used for post hoc comparisons as needed. Three separate analyses then were conducted to determine the independent contributions of sociodemographic and other variables to maternal PSI scores. First, two-step hierarchical regression was performed to determine which variables predicted mothers' mean PSI total scores. Next, logistic regression was performed to assess whether the same variables could independently predict which mothers would have PSI scores at or greater than a clinically important cutoff of 30. Finally, a discriminant function analysis was conducted to assess how sensitive maternal sociodemographic and other variables were at classifying mothers with PSI total scores ≥30 or <30.
RESULTS
Of 304 eligible mothers who were asked to participate, 279 (92%) agreed. Of the 279 respondents, 86% self-administered the PSI and 14% required minimal assistance to complete the measure. Mean PSI total scores did not differ by administration method (self-administered versus assisted).
Sample Characteristics
Sociodemographic characteristics are shown in the first column ofTable 1. Mothers ranged in age from 14 to 48 years (mean, 27 years). Most were unmarried (71%) and almost one-third lived alone with their children. Forty-two percent of mothers were Hispanic, 40% were black, 9% were white, and the remainder (10%) were mixed or other races. Forty-eight percent of mothers were born outside the continental United States, including 9% who were born in Puerto Rico. The average grade level completed was grade 12 (range, 5th–17th). English was the primary language for 56% of mothers.
Mean PSI Scores by Sociodemographic Characteristics of Mothers (n = 279)
The first column of Table 2 shows mothers' self-reports of financial status, health status, and global well-being. Twenty-seven percent of mothers had never worked outside the home, whereas 24% were currently employed. More than half received public assistance. Sixty-three percent of mothers reported that their financial situation was “fair,” “poor,” or “very poor.” When asked about their health, 7% of mothers reported that their health was “poor” or “fair” compared with 29% who stated that their health was “good” and 63% who stated their health was “very good” or “excellent.” Twenty-four percent of mothers had a chronic medical condition; 6% reported one or more activity limitations because of an illness or medical condition. When asked a global question about how happy they were, 8% of mothers responded that they were “not happy,” 54% were “pretty happy,” and 38% were “very happy.”
Mean PSI Scores by Self-reported Characteristics of Mothers (n = 279)
Depressive Symptoms
The mean PSI total score was 19 (range, 0–75). Thirty-nine percent of mothers scored ≥20, and 18% had PSI total scores of ≥30. Anxiety and depression subscales were highly correlated with PSI total scores (0.8 and 0.9, respectively).
The second and third columns of Table 1 show PSI total scores by maternal sociodemographic characteristics. The results are reported both as the mean PSI total score for each type of maternal characteristic and as the proportion of mothers within each group with PSI total scores that reflected high symptom levels (≥30). Although the PSI is not intended to yield or imply a psychiatric diagnosis, we determined the proportion of mothers in each group who had PSI scores ≥30 as one way to address the clinical significance of the association between distress and particular maternal sociodemographic characteristics.
Within this sample, mean PSI total scores did not vary significantly by most sociodemographic characteristics including race, birthplace, marital status, age, educational level, employment status, or family composition. Although educational level was not significantly related to mean PSI total score, a significantly larger proportion of mothers with less than a high school education had PSI scores ≥30 (P < .05). Also, more mothers who were previously married (divorced or separated) had PSI scores ≥30 when compared with other mothers, but the difference was not statistically significant (P < .10), possibly as a result of the small number of mothers in the previously married group.
As shown in Table 2, there were significant relationships between maternal self-reports of financial status, health status, and global well-being and their PSI total scores. Mean PSI total scores were significantly higher among mothers receiving public assistance than those who were not (21 vs 17, P < .05). In addition, a significantly larger proportion of mothers receiving public assistance had PSI total scores ≥30. Mothers who reported good or very good financial status had lower mean PSI total scores than those who reported very poor to fair financial status (15 vs 22,P < .005). Likewise, a larger proportion of mothers who reported poor to fair financial status had PSI total scores ≥30.
Mothers with self-reports of poor health status had extremely high mean PSI total scores (52, P < .005). As reported health status improved, mean PSI total scores decreased. The proportions of mothers with PSI total scores ≥30 also increased significantly as reported health status declined from excellent to poor. Mothers who reported activity limitations because of illness had significantly higher PSI total scores than did mothers with conditions but no activity limitations or mothers who were healthy (34 vs 21 vs 18,P < .005), and a larger proportion of this group also had PSI total scores ≥30.
In terms of their global happiness, mothers who reported being “not happy” had much higher PSI total scores than those who reported being “pretty happy” or “very happy” (31 vs 20 vs 15,P < .005). In addition, half of mothers who reported being “not happy” had PSI total scores ≥30.
Based on significant bivariate relationships, we conducted a two-step hierarchical linear regression to determine the independent relationships of mothers' ratings of their health, financial status, and global happiness to PSI total score controlling for sociodemographic factors (Table 3). In the first step, we entered the six sociodemographic factors that either demonstrated trends in their association to or had statistically significant relationships with maternal symptoms (black race, mother living alone with children, on public assistance, born in the United States, having less than a high school education, or having been previously married) as a block and found that none of these factors significantly predicted mothers' PSI total scores. In Step 2, we entered four maternal self-reported variables (fair/poor financial status, not happy, medical condition with activity limitation, and poor/fair/good health status) that had had significant bivariate associations with PSI score. Three of the four maternal self-reported status variables (financial status, global happiness, and activity limitation) uniquely contributed to the overall prediction (P values <.05). The relationship of poor/fair/good health status was borderline (P = .07). The overall variance accounted for by the maternal self-reported status was significant (adjusted R2 = 0.16,P < .0001).
Linear Regression Analysis: Predictors of PSI Score
To determine if the same maternal characteristics could predict the presence of very high levels of maternal symptoms, or PSI ≥30, we next performed logistic regression (Table 4). Using the same sociodemographic variables in the first step as were used in the linear regression, we found that none was significant in predicting the presence of a PSI total score ≥30. When we entered the same four maternal self-reported status variables either as forced entry or stepwise entry, we found that fair/poor financial status, poor/fair/good health status, and a global assessment of being not happy each contributed significantly and uniquely in the model to predict which mothers had PSI total scores ≥30 (P < .05). In this analysis, having an activity limitation did not significantly predict PSI total score ≥30, possibly because of the small number of mothers in that group.
Logistic Regression: PSI ≥30 by Selected Maternal Characteristics
Finally, a discriminant function analysis was performed. Using the same sociodemographic and self-reported variables, we found that sociodemographic characteristics alone correctly classified 56% of mothers as having PSI total scores ≥30 or <30. When mother's self-reported status variables (fair/poor financial status, not happy, medical condition with activity limitation, and poor/fair/good health status) were added to the sociodemographic variables, 73% of mothers were correctly classified. However, the four self-reported status variables did as well in correctly classifying mothers when used alone (74%). This suggests that sociodemographic characteristics in this sample were of no added benefit in predicting maternal PSI total scores.
DISCUSSION
Depressive symptoms in this sample of inner-city mothers of young children were common, with almost 40% of mothers showing high levels of symptoms on the PSI using a cutoff score of 20 or more. Furthermore, a substantial percentage of mothers (18%) scored ≥30, suggesting the presence of major depressive disorder in a large number of mothers. The mean PSI total score of 19 in this population was also higher than that found by Ilfeld (mean, 10.5).49 These findings are consistent with other investigators who have found high rates of depressive symptoms among mothers in the inner city.8,,10,13
As we hypothesized, sociodemographic factors that have been identified as risk factors for depressive symptoms by other investigators were not useful in this relatively homogeneous sample of high-risk women to detect mothers with high levels of depressive symptoms. With the exceptions of having less than a high school education and receiving public assistance, sociodemographic factors alone were not helpful in predicting which mothers were at risk for high levels of depressive symptoms. However, a number of easily assessed maternal factors were associated with higher PSI scores. These included mothers' self-report of poor or fair financial status; poor, fair, or good health status; or activity limitation because of illness. In addition, mothers who responded negatively to a global question asking how happy they were had higher PSI scores than those who responded positively. Within this inner-city population, these self-reported factors were significant predictors independent of mothers' sociodemographic characteristics, and, in fact, did as well when used alone to correctly classify mothers as having PSI total scores ≥30 or <30.
In populations of inner-city mothers where there may be little variation among sociodemographic characteristics, asking a few simple questions may enable pediatric health care providers to identify mothers with high levels of depressive symptoms. First, pediatricians can and should ask questions about financial status to identify mothers at risk. Self-reported financial status may reflect mothers' level of financial stress. Two additional questions that may reflect financial stress in our study were also significantly associated with higher levels of depressive symptoms: having less than a high school education and receiving public assistance. Second, pediatricians can ask about mothers' health status. The Agency for Health Care Policy Research (AHCPR) Depression Guideline Panel noted that many general medical conditions are risk factors for major depression.58Therefore, mothers with medical conditions, particularly those with activity limitations, are at higher risk for depressive symptoms. Although the PSI and other screening checklists contain items that reflect physiologic as well as psychologic symptoms, Ilfeld59 found that when the depression and anxiety items of the PSI are divided into a psychologic symptom scale and a physiologic symptom scale, sociodemographic factors relate to psychologic and physiologic symptoms equally. Our findings were similar. Mothers with activity limitations because of illness had higher PSI total scores than those without medical conditions when psychologic items and physiologic items were scored separately. This suggests that the PSI measures psychologic distress, although it contains items that reflect physiologic and somatic complaints. In addition, the higher scores of mothers with medical conditions are not simply because of elevated somatic symptoms.
Finally, asking mothers a global question like, “How are things going for you?” proved helpful in identifying mothers with high levels of depressive symptoms. Not only can this nonthreatening, informative question build rapport, but, when asked in the context of child-centered health care, may also provide pediatricians with extremely useful information about a mother's mental health and well-being.
Depression among mothers is common and may negatively affect children, but many mothers fail to be identified as having a disorder through their own use of medical care services.20–21Therefore, they are unlikely to receive mental health treatment. However, most mothers do bring their young infants and toddlers for pediatric care on a regular basis. The American Academy of Pediatrics recommends 12 visits for children in the first 3 years of life.60 Therefore, pediatric primary care visits may provide a strategic opportunity to identify mothers with symptoms of depression. In addition, pediatricians are motivated to identify psychologic problems in mothers because they are aware of the impact these problems may have on children. As Zuckerman and Beardslee61 stated, “After pregnancy, the pediatric primary care system may represent the only health system in which parents are consistently involved and provides a window of opportunity to address their health.”
Because pediatricians develop an ongoing relationship with mothers and discuss various stresses experienced in parenting children, pediatricians may be in an excellent position to identify mothers already having or at risk for depressive symptoms and disorders. Women who may not have a primary health care provider of their own, or who may not feel comfortable discussing their concerns with their own physician, may be more inclined to openly discuss problems that affect their children, such as depressive symptoms, with pediatricians. Simonian et al62 noted that screening for adult mental health problems and family stresses is a promising avenue by which primary care pediatric providers can increase their effectiveness at dealing with and preventing childhood problems. Healthy Children 200063 also calls for increasing the number of “primary care providers who include in their clinical practices assessment of cognitive, emotional, and parent-child functioning, with appropriate counseling, referral, and follow-up.”
Further study is needed to explore the best ways to help pediatricians recognize mothers at risk for depressive symptoms. We found that by asking mothers just a few simple questions about their current financial status, health status, and global well-being, pediatricians could learn a great deal about a mother's potential risk. As demonstrated in the discriminant function analysis, these four maternal self-reported status questions can be used to correctly classify three-quarters of mothers who may be at risk. These questions do not add additional time to a primary care encounter, yet are quite informative. With only slightly more effort, a screening tool such as the PSI is also quite useful to pediatricians in identifying mothers who are experiencing elevations in depressive symptoms. Other investigators also have advocated using brief screening tools in pediatric settings to identify families at high risk for a number of psychosocial problems including depression, domestic violence, substance abuse, and homelessness.10,64–66 Because depressive symptoms correlate with other forms of psychopathology, particularly anxiety, many validated measures are currently available to assess depressive symptoms, such as the CES-D50 and the BDI,67and a wider array of psychopathology, such as the PRIME-MD.68
The PSI has been shown to have good sensitivity and specificity against a well-validated diagnostic psychiatric interview in the diagnosis of major depressive disorder. However, we believe that it is important to identify women with high levels of depressive symptoms that do not qualify for a diagnostic label. The presence of depressive symptoms even without a clinical diagnosis of depression may contribute significantly to poor child outcomes such as behavioral problems.41,,66,69 In addition, Brown et al70showed that both chronic and severe life stress with subclinical symptoms may be important contributors to the development of depressive disorders. Furthermore, interventions to prevent the progression of depressive symptoms into an episode of major depressive disorder are currently available and have been found to be effective in some patients.71
The findings from this study indicate that screening for maternal depressive symptoms in a pediatric primary care setting is feasible. Given the magnitude of the problem in this population, we believe that screening inner-city mothers is also necessary. Recognizing the problem is the first step, however, and should be done in the context of available treatment services for mothers. Because effective treatment strategies exist for depression and depressive symptoms,72,,73 pediatricians can be a valuable resource to mothers and children if they are willing and prepared to refer mothers who may need further evaluation and treatment. Although many pediatricians may not feel either willing or prepared to recognize maternal depressive symptoms, we assert that maternal mental health directly affects children and is an important consideration for health care providers of children. Additional research to assess pediatricians' awareness of the presence of depressive symptoms in mothers of their patients, as well as mothers' and pediatricians' willingness to discuss depressive symptoms in the context of health care for children, is certainly needed. Ultimately, we aim to develop effective ways for pediatricians to identify and address this prevalent problem that has profound effects for children and mothers alike.
ACKNOWLEDGMENTS
The authors thank the New York City Health and Hospitals Corporation and the Jacobi Medical Center for their cooperation.
Footnotes
- Received October 24, 1997.
- Accepted July 1, 1998.
Reprint requests to (A.M.H.) Department of Pediatrics, Albert Einstein College of Medicine, NR 7S19, 1300 Morris Park Ave, Bronx, NY 10461.
This work was presented in part at the 37th Annual Meeting of the Ambulatory Pediatric Association, Washington, DC, May 3, 1997.
- PSI =
- Psychiatric Symptom Index
REFERENCES
- Copyright © 1998 American Academy of Pediatrics
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