Coping and Suicidal Ideations in Women with Symptoms of Postpartum Depression

Clinical Medicine: Reproductive Health O r i g i n a l R e s e a r c h Open Access Full open access to this and thousands of other papers at http://www.la-press.com. Coping and Suicidal Ideations in Women with Symptoms of Postpartum Depression S. Doucet 1 and N. Letourneau 2 1 PhD student in Interdisciplinary Studies at the University of New Brunswick (UNB); Stipend instructor, University of New Brunswick Department of Nursing, PO Box 5050, Saint John, NB, Canada. 2 Professor, Faculty of Nursing and Canada Research Chair in Healthy Child Development at UNB, PO Box 4400, Fredericton, NB, Canada. Email: nicolel@unb.ca Abstract Objective: To explore the relationship between coping mechanisms and suicidal ideations among women who experience symptoms of postpartum depression. Design: This exploratory descriptive study used secondary data from a study of women who experienced symptoms of postpartum depression. Participants: Convenience and purposive sampling were used to obtain the community sample of 40 women who experienced symptoms of postpartum depression. Methods: Binary logistic regression was employed to explore emotion-focused coping, avoidance-focused coping, problem-focused coping, and religious coping as predictors of suicidal ideations. Results: Approximately 27% of the sample reported suicidal ideations within the past seven days. The results showed that lower levels of emotion-focused coping and higher levels of avoidance-focused and religious coping predicted suicidal ideations in participants. Problem-focused coping did not predict suicidal ideations. Conclusion: Overall, our findings provide support for the importance of coping mechanisms as predictors of suicidal ideations among women who experience symptoms of postpartum depression. The results illustrate the need for health professionals to conduct routine assessments on coping strategies and thoughts of suicide when caring for postpartum women, as well as the need to integrate coping approaches in the prevention and treatment of suicidal ideations. Keywords: coping, postpartum depression, suicidal ideations Clinical Medicine: Reproductive Health 2009:2 9 19 This article is available from http://www.la-press.com. the author(s), publisher and licensee Libertas Academica Ltd. This is an open access article. Unrestricted non-commercial use is permitted provided the original work is properly cited. Clinical Medicine: Reproductive Health 2009:2

Doucet and Letourneau Introduction Postpartum depression (PPD) is a serious health concern worldwide. A widely cited review of 59 studies revealed that 13% of new mothers experience PPD within 12 weeks of giving birth. 1 More recent reports suggest rates as high as 15% in community samples. 2 Depression is more than low mood; it is the most common mental illness leading to suicide. In the postpartum period, the most common cause of maternal death is suicide, often associated with postpartum depression. 3 The prevalence of suicidal ideation in the postpartum period ranges from 0.2% to 15.4% among diverse populations, 4 with variation likely due to measurement, sample selection (e.g. depressed or non-depressed) and cultural factors. In spite of the apparent risks, little is known about suicidal ideations, including thoughts or behaviors related to self-harm, among women who experience postpartum depression. Coping mechanisms have been suggested as one avenue to understand depression in the postpartum period. 5,6 To date, no research has explored coping mechanisms as predictors for suicidal ideations in the postpartum period among women who experience symptoms of depression. Suicidal ideations are comprised of thoughts, feelings, and behaviors that range from momentary vague thoughts of suicide to detailed and well thought out plans to terminate one s life. Coping mechanisms are characterized as thoughts and behaviors that have the potential to influence whether or not suicidal ideation features as a symptom in a mother s PPD. The serious consequences associated with suicidal ideation for women, families, and health care providers charged with caring for women with postpartum depression, press for an increased understanding of this troubling symptom. An exploration of the relationship between coping mechanisms and dangerous suicidal thoughts is critical to this understanding. Literature Review There are discrepancies in the empirical literature on the prevalence of suicidal behaviors postpartum. Several researchers 7 9 suggest that women are less likely to attempt or commit suicide in the postpartum period, and as a result, they consider childbirth to reduce suicidal risk. Research suggests, however, that women who experience mental illness are more likely to commit suicide postpartum. 3 Women with severe postpartum psychiatric disorders have been shown to have a 70-fold increased risk of suicide during the first postpartum year. 10 Suicidal behaviors occur on a continuum, ranging in severity from suicidal ideations, to suicide attempts, to completed suicides. 11 Postpartum research focuses primarily on those who attempt or commit suicide, with less attention accorded to those who have suicidal ideations. Although women with suicidal ideations are distinct from those who attempt and commit suicide, these are overlapping populations. Several researchers have reported that suicidal ideations and suicide attempts are strong risk factors for completed suicides. 12 17 The risk of suicide is approximately 10 times greater in people who have a history of suicide attempts 12 and 7 times greater in people who have a history of suicidal ideations. 13 Accordingly, it is important to determine the predictors of suicidal ideations in order to intervene before more serious suicidal behaviors occur. Demographic and perinatal related suicidal risk factors Demographic factors, such as women who are unmarried, 7,18 young, and of low socioeconomic status, 18 are suggested to be risk factors for suicide postpartum. Perinatal factors, including fetal and infant death, are also thought to be predictors of suicidal behaviors postpartum 7,18 20 although these risk factors are in contrast to Turner, Krame, and Li s 9 findings. Perinatal factors that have not been found to be related to suicidal behaviors postpartum include preterm delivery, labor and delivery complications, low infant birth weight, and congenital malformations. 19 By and large, very little is known about the demographic and perinatal-related risk factors for suicidal behaviors in the postpartum period. Coping and suicidal ideations Coping consists of the thoughts and behaviors people use to manage the demands of stressful experiences. 21 Approaches to coping are not intrinsically positive or negative; rather they are adaptive depending on the situation and the stressful life event in which they are used. Mothers may rely on coping strategies in the postpartum period to help them manage stressors associated with daily hassles and new childcare responsibilities. 5 Coping is often categorized into emotion-focused and problem-focused. 21 Emotion-focused approaches 10 Clinical Medicine: Reproductive Health 2009:2

Coping and suicidal ideations regulate emotional distress (e.g. seeking sympathy and understanding). Problem-focused approaches direct attention towards the problem and look for ways to resolve it (e.g. interpersonal efforts to alter the situation). Endler and Parker 22 additionally suggest avoidance-focused coping as a category, which entails person-oriented or task-oriented strategies to distract away from the stressor at hand. Others have described religious faith and spiritual beliefs as a means of coping. 23 25 The transition to parenthood is often reported to be a stressful life event; however, no study yet has explored coping mechanisms as predictors specific to suicidal ideations postpartum. As such, insights may be gleaned from studies of coping strategies and suicidal ideations with other populations, which are reviewed here. Avoidance-focused and emotionfocused coping Several researchers have reported the importance of avoidance-focused and emotion-focused coping as predictors of suicidal ideations. In HIV positive patients, suicidal ideations were more likely to be experienced by individuals who cope through avoidance and escape strategies. 26 The relationship between greater reliance on avoidance coping and suicidal ideations has also been demonstrated among psychiatric inpatients. 27,28 Avoidance coping as a risk factor for suicidal ideations was not supported in a sample of adult medical inpatients, while higher levels of emotion-focused coping were predictive of suicidal ideations. 29 Female undergraduates who used emotion-focused coping were also more likely to experience suicidal ideations. 30 Overall, avoidance-focused and emotion-focused coping are often reported to be less effective strategies, primarily because these approaches do not address the direct management of the problem at hand. This exacerbates the stressful experience, and in turn can lead to suicidal behaviors as a means to escape. 30 Problem-focused coping Problem solving as a coping strategy is thought to reduce the risk of suicidal ideations. In a college sample, problem solving deficits predicted increased suicidal ideations, regardless of the stress level. 31 Low self-appraisal of problem solving ability has also been associated with increased thoughts of suicide. 32,33 Taking into consideration the evidence on the relationship between problem-solving ability and suicidality, a randomized controlled trial was conducted with college students of a brief problem-solving video and the intervention was found to be effective in decreasing suicidal ideations and depressive symptoms. 11 As a whole, problem-focused coping is recognized to be an effective approach, as the individual takes active steps towards resolving the problem that is causing their distress. Religious coping Religious coping appears to decrease the risk of suicidal ideations. Among depressed adults with a history of child abuse, an inverse relationship was demonstrated between the severity of suicidal ideations and religious beliefs. 23 Religious coping decreased the risk of suicidal ideation among African American and White college students 24 and Latin American immigrants. 25 Religion may protect against suicidal thoughts by providing meaning in people s lives, as well as by fostering a sense of hope for the future. Summary Emotion-focused coping, avoidance-focused coping, problem-focused coping, and religious coping are important predictors of suicidal ideations among a variety of populations. Accordingly, the main objective of this study was to explore whether these coping strategies predict suicidal ideations among women who experience symptoms of PPD. Gaining a better understanding of coping approaches that predict suicidal ideations is critical to creating effective prevention and treatment interventions for women with PPD. A secondary objective was to explore whether any differences in demographic and perinatal-related factors exist between (1) women who experience symptoms of PPD and have suicidal ideations and (2) women who experience symptoms of PPD and do not have suicidal ideations. Research Questions and Hypothesis Based on expectations from the preceding review of the literature, the following research questions were formulated for this study: 1. Do women who experience symptoms of PPD who report suicidal ideations differ from those who do Clinical Medicine: Reproductive Health 2009:2 11

Doucet and Letourneau not in relation to age, marital status, employment status, income, and normal pregnancy/delivery? 2. How well does the overall model with emotionfocused, avoidance-focused, problem-focused, and religious coping strategies predict the likelihood that women who experience symptoms of PPD would report suicidal ideations? 3. What coping mechanisms best predict the likelihood that women would report suicidal ideations? In addition, the following research hypothesis was formulated for this study: Among women who experience PPD, higher levels of emotion-focused coping and avoidance-focused coping and lower levels of problem-focused coping and religious coping will predict the presence of suicidal ideations. Methods Design This exploratory, descriptive study consists of a quantitative secondary analysis of data generated from the Child Health Intervention and Longitudinal Development (CHILD) studies program. 34 The data was originally collected to explore the support needs of women who experience PPD. In this study, the quantitative data collected on coping mechanisms and suicidal ideations were examined. Ethics approval was granted for the primary study, and appropriate methods were used to safeguard participants privacy. Setting The original study was set in two Canadian provinces, Alberta (AB) and New Brunswick (NB). Participants were from urban and rural areas respectively. Sample The target population for this study was women who experienced symptoms of depression in the postpartum period. Using a combination of convenience and purposive sampling, a total of 40 women (AB n = 24, NB n = 16) were recruited in to the study. Potential participants were recruited through various advertisements, including: newspapers, regional television and radio stations, psychiatrists and psychologists offices, mental health clinics, public health clinics, and health care facilities, such as maternity wards and mother-baby clinics. To assess eligibility for inclusion, mothers were screened using a tool designed for this study based on the DSM-IV-TR criteria for major depression in the postpartum period. 35 Included mothers had to report that their symptoms: a) began within 12 weeks of delivery, b) lasted more than two weeks, and c) had a functional impact on ability to care for herself or her child. Mothers were excluded if they reported a comorbid mental health diagnosis. Data collection procedures The data used in this study were collected through faceto-face interviews that were conducted in women s homes or at another place of their choosing (e.g. university or health agency). Interviews were conducted by trained research assistants with graduate preparation in nursing or an allied health discipline. Data obtained from two quantitative instruments were used to explore the research questions and hypothesis: the Edinburgh Postnatal Depression Scale 36 and the Brief COPE. 37 A personal data sheet was also used to collect demographic information. Edinburgh postnatal depression scale Suicidal ideations in the postpartum period were assessed using the 10-item Edinburgh Postnatal Depression Scale (EPDS), developed by Cox et al. 36 This standardized instrument is a self-report measure that assesses how postpartum women felt during the past seven days. Items are rated on a 4-point Likerttype scale according to the frequency that the feelings occur. Item number 10 relates to self-harm, and response choices range in severity from 0 = never to 3 = yes quite often. Participants who reported scores greater than 0 on item 10 were included in the suicidal ideation group. The measure provides a score that ranges from 0 to 30, with higher scores indicative of more symptoms of postpartum depression. A score of 9 or greater is indicative of significant symptoms of PPD, while a score of 12 or greater correlates well with physician diagnosis of major depression in the postpartum period. 36,38 Brief COPE Coping mechanisms were measured using the 28-item Brief COPE, 37 which is a shortened version of the 60-item COPE. 39 The Brief COPE measures 14 coping styles, with two items representing each style. Participants were asked how they have coped with the stress in their life since they began 12 Clinical Medicine: Reproductive Health 2009:2

Coping and suicidal ideations experiencing PPD. Items are rated on a 4-point Likert-type scale according to the frequency in which the coping approaches are used, with response choices ranging from 1 = I haven t been doing this at all to 4 = I ve been doing this a lot. 39 Items are based upon Lazarus and Folkman s 21 model of coping and Carver and Scheier s 40 model of behavioral self-regulation. Carver 37 recommends only using the scales that are of interest to the researcher. Accordingly, only the following four coping scales were examined: using emotional support, self-distraction, active coping, and religion. The using emotional support scale is considered an aspect of emotion-focused coping, and assesses the use of moral support, sympathy, or understanding. 39 For avoidance-focused coping, the self-distraction scale was selected, in keeping with Endler and Parker s 22 conceptualization of avoidance coping. The self-distraction scale assesses the degree to which the respondent does things to take one s mind off the stressor. 39 The active coping scale is considered by Carver et al 39 to be very similar to Lazarus and Folkman s 21 description of problemfocused coping, and assesses the degree to which active steps are taken to remove the stressor or to improve its effects. Finally, the religion scale assesses the tendency to turn to religion during stressful times. 39 Using Cronbach s alpha, Carver et al. 39 reported good internal reliability for the coping scales used in this study, ranging from 0.68 to 0.82. The internal reliability estimates (Cronbach s alpha) obtained in the present study are as follows: using emotional support, 0.84; self-distraction, 0.72; active coping, 0.73; and religion, 0.78. Data analysis and power Descriptive statistics (means, standard deviations, and percentages) were generated to describe the sample. Inferential statistical analyses were used to test the study hypothesis and questions by conducting binary logistic regression. Logistic regression is used to determine how well a set of continuous or categorical independent variables predict a categorical dependent variable. In this study, suicidal ideation was the outcome variable, with the four coping mechanisms entered as predictors. The assumptions for using logistic regression were met. Chi-square tests and independent t-tests were also employed to compare differences between the women who experienced suicidal ideations and those who did not on demographic and perinatal-related risk factors. All statistical tests with p values of less than 0.05 were considered statistically significant. Given the sample size of 40 and the necessity of 10 participants per predictor to maintain adequate power to support study findings, only four predictor variables were able to be included in the logistic regression model. Thus potential confounders were not examined as the sample size provided inadequate statistical power for these analyses. Moreover, the purpose of the study was to examine the relationship between coping and suicidal ideation and not to develop a full model to explain the relationships among coping, suicidal ideation and other covariates. Results Table 1 provides a detailed description of the women s demographic and descriptive characteristics. The women ranged in age between 20 and 41 years. No significant differences were found on any of the demographic or descriptive variables except for EPDS total scores (t = 3.20, CI: 2.03, 9.0, p = 0.003). Approximately 28% of the women reported thoughts of suicide in the past seven days. To answer our first question, we compared the suicidal ideation group (n = 11) with the non-suicidal ideation group (n = 29) and found no significant differences between the two groups in relation to age, marital status, employment status, income, and normal pregnancy/delivery or symptoms of depression as measured by the EPDS. Logistic regression was employed to answer our second question, How well does the overall model with emotion-focused, avoidance-focused, problemfocused and religious coping strategies predict the likelihood that women who experience PPD would report suicidal ideations? All variables were entered on the first block, which was statistically significant χ² (4, n = 40) = 25.621, p 0.001, indicating that the model was able to distinguish between women who report suicidal ideations from those who do not. The model as a whole accounted for 46.5% (Cox and Snell R square) to 67.6% (Nagelkerke R square) of the variance in suicidal ideation, and correctly classified 92.7% of the cases. The Hosmer and Lemshow test indicates a good model fit (p = 0.889). The sensitivity Clinical Medicine: Reproductive Health 2009:2 13

Doucet and Letourneau Table 1. Demographic and descriptive data of women who did (EPDS item 10 score 1; n = 11) and did not (EPDS item 10 score = 0; n = 29) report suicidal ideation. Variable EPDS item 10 score = 0 EPDS item 10 score 1 Mean SD Mean SD Age 31.2 5.47 30.8 5.12 EPDS Score 10.0 4.76 15.5 5.15 Age of youngest child in months 9.5 5.35 14.6 9.92 n (%) n (%) Number of children in household One child 15 51.7% 8 72.7% Two children 8 27.6% 1 9.1% Three children 5 17.2% 2 18.2% Four children 1 3.4% Marital status Married 24 82.8% 9 81.8% Single 3 10.3% 1 9.1% Common law 2 6.9% Divorced 1 9.1% Ethnicity Caucasian 23 79.3% 9 81.8% Aboriginal/Native 4 13.8% Hispanic, Asian, other 2 6.8% 2 18.2% Employment Maternity leave 11 37.9% Homemaker 5 17.2% 3 27.3% Part-time 5 17.2% 2 18.2% Full-time 2 6.9% 3 27.3% Unemployed 3 10.3% 2 18.2% Student 2 6.9% 1 9.1% Other 1 3.4% Highest level of education Completed college/university 17 58.6% 7 63.7% Partial college/university 5 17.2% 2 18.2% Completed high school 6 20.7% 1 9.1% Partial high school 1 3.4% 1 9.1% Normal pregnancy Yes 10 34.5% 5 45.5% No 14 48.3% 4 36.4% Missing 5 17.2% 2 18.2% Household income $19,999 or less 4 13.8% 3 27.3% $20,000 $39,999 2 6.9% 2 18.2% $40,000 $69,999 12 41.4% 4 36.4% (Continued) 14 Clinical Medicine: Reproductive Health 2009:2

Coping and suicidal ideations Table 1. (Continued) Variable EPDS item 10 score = 0 EPDS item 10 score 1 Mean SD Mean SD n (%) n (%) $70,000 $99,999 8 27.6% 2 18.2% $100,000+ 2 6.9% Missing 1 3.4% Province Alberta 18 62.1% 6 54.5% New brunswick 11 37.9% 5 45.5% Medication for PPD symptoms Yes 15 62.5% 3 27.3% No 9 31.0% 5 45.5% Missing 5 17.2% 3 27.3% Suicidal ideations Never 29 100% Hardly ever 7 63.6% Sometimes 4 36.4% Abbreviations: SD, standard deviation; n, number in sub-sample; EPDS, Edinburgh Postnatal Depression Scale. of the model in predicting suicidal ideations was 81.8%, while the specificity in predicting those who do not have suicidal ideations was 96.7%. By examining the coefficients of each predictor in the logistic regression model, we answered our third question, What coping mechanisms best predict the likelihood that respondents would report suicidal ideations? As is shown in Table 2, emotionfocused, avoidance-focused, and religious coping made statistically significant contributions ( p 0.05); while problem-focused coping did not contribute significantly to the model. The strongest predictor for suicidal ideations among women who experience PPD was emotion-focused coping. Contrary to expectations, the inverted odds ratio for emotionfocused coping indicates that as emotion-focused coping ratings decreased, the odds of reporting suicidal ideations increased. Avoidance-focused coping was the next best predictor of suicidal ideations, with the odds of suicidal ideations increasing as avoidancefocused coping increased. Finally, and to our surprise, higher levels of religious coping was associated with an increased likelihood of reporting suicidal ideations. Discussion The aim of this study was to explore coping mechanisms as predictors for suicidal ideations among women who experience PPD. Overall, the results obtained provide beginning evidence for the relationship between coping mechanisms used by women who experience PPD and the likelihood that they will report suicidal ideations. Most notably, the findings indicate that lower levels of emotion-focused coping and higher levels of avoidance-focused and religious coping predict suicidal ideations among women who experience PPD. Inconsistent with much of the existing literature on coping and suicidal ideations, the role of problemfocused coping as a predictor of suicidal ideations was not supported in this study. Emotion-focused coping As hypothesized, emotion-focused coping significantly predicted suicidal ideations among postpartum women. Of interest, however, is that lower levels of emotionfocused coping actually increased the likelihood of having suicidal ideations. A possible reason for this may lie in the conceptualization of emotion-focused coping. We used only one aspect of this approach to Clinical Medicine: Reproductive Health 2009:2 15

Doucet and Letourneau Table 2. Logistic regression predicting suicidal ideations from coping strategies of women who reported symptoms of PPD. Predictor B S.E. Wald OR (95% C.I.) Emotion -1.825 0.806 5.134* 0.161 (0.033 0.782) Avoidance 1.736 0.723 5.769* 5.672 (1.376 23.380) Problem 0.014 0.971 0.000 1.014 (0.151 6.807) Religion 1.460 0.638 5.229* 4.304 (1.232 15.039) Note: N = 40; *p 0.05. Abbreviations: OR, odds ratio; CI, confidence interval. coping, namely using emotional support. Carver and colleagues 39 suggest that the use of emotional support can act as a double-edged sword. For instance, the use of emotional support to vent one s feelings is a passive approach to addressing a problem, and is often not adaptive. In contrast, the adaptive use of emotional support often entails reassurance during periods of acute stress, the transition to move to more active coping approaches can be enhanced. In this study, it appears that women who used emotional support as a coping approach were protected from having suicidal ideations. Additional research is warranted to clarify the relationship between emotion-focused coping and suicidal ideations in the postpartum period. Avoidance-focused coping In keeping with past research 26 28 this study suggests that the use of avoidance-focused coping, as measured by self-distraction, increases the likelihood of having suicidal ideations. The use of self-distraction impedes active coping, as one mentally disengages from the problem at hand. Further studies should investigate interventions that address the prevention of avoidancefocused coping in the postpartum period and the effects these interventions have on decreasing the risk of suicidal behaviors postpartum. Religious coping The present study also demonstrates support for the importance of religious coping as a significant predictor of suicidal ideations. The direction of this relationship, however, was not as predicted. While spiritual and mystical feelings and thoughts have been described as a means to cope in times of mental distress, 41 we found women who reported higher levels of religious coping were more likely to report suicidal ideations. Recently, Huguelet et al 42 studied suicide attempts and religious coping and found religion was an incentive for suicidal behaviors in one out of ten participants. For instance, respondents reported a wish to die to be with God, religious delusions and hallucinations, and a mystical experience of death. Due to the possibility that religion may both foster and prevent suicidal behaviors, caution should be taken when using religious coping approaches as interventions. Further research is warranted. Problem-focused coping Problem-focused coping, as reflected by the active coping measure, did not significantly predict the likelihood of suicidal ideations, unlike other research. 27,31,43 Most research on problem solving as a coping strategy has supported problem-solving appraisal as a predictor of suicidal ideations 32,33 and our measure may not reflect how one appraises their ability to problemsolve. Problem-focused coping may only be effective when one self-appraises capability in solving the problem. Moreover, problem-focused coping is generally effective when the stressful event is perceived to be changeable or controllable. 21 Women who experience PPD may not perceive their situation to be changeable, and thus may be less likely to use problem-focused coping. Future research should explore the appraisal of problem-focused coping in relation to suicidal behaviors, as well as women s experiences with this approach in the postpartum period. Demographic risk factors This study also aimed to explore demographic and perinatal related risk factors for having suicidal ideations among women who experience PPD. While it has been shown in previous research studies that demographic and perinatal-related factors can pose a risk for suicidal behaviors postpartum, the current study did not demonstrate statistically significant 16 Clinical Medicine: Reproductive Health 2009:2

Coping and suicidal ideations differences between the suicidal ideation group and the non-suicidal ideation group in relation to age, marital status, employment status, income, and normal pregnancy/delivery. It is plausible that we did not find any differences because our sample size was too small. On the other hand, it is possible that these two groups are not different on these variables. We suggest these findings be replicated in future studies. Implications for healthcare professionals The findings from this study demonstrate an alarming prevalence of suicidal ideations among women who experience PPD. Accordingly, healthcare professionals in all settings need clinical knowledge on postpartum suicidal behaviors in order to prevent, detect, intervene, and advocate for women in the postpartum period who have suicidal ideations. To detect the presence of depression and suicidal ideations, we suggest that healthcare professionals incorporate the EPDS into routine postpartum visits. According to the Registered Nurses Association of Ontario, 44 women who report a score of one or greater on thoughts of self-harm (Item 10) require immediate attention and thus appropriate treatment and referral mechanisms must be in place. Healthcare professionals could work with women who experience symptoms of PPD to educate and counsel them on effective coping strategies that decrease the risk of suicidal ideations. Given the reported beneficial association of emotion-focused coping, women should be encouraged to use emotional supports to deal with stressors in their lives. For women who experience PPD, receiving support from other women with children is particularly important in recovery. 45 Peer support groups are ideal settings for women to receive non-judgmental and empathetic support in safe environments to deal with stressors in the immediate postpartum period, 46 especially considering this form of support is preferred by women who experience PPD. 34,45 Risk assessments should address women who use avoidance-focused and religious coping approaches. Healthcare professionals are encouraged to explore with women how they use religious coping and the meaning they place on their spirituality. We believe that there are no approaches to coping that are fundamentally positive or negative; rather coping approaches are adaptive or maladaptive depending on the context in which they are used. Accordingly, healthcare professionals should not only explore what coping approaches postpartum women use, but also the ways in which these approaches are used, as well as their effects. More research is needed before more extensive recommendations can be made. Future research recommendations Although the present study demonstrates the importance of coping strategies as predictors of suicidal ideations, much remains to be learned about suicidal behaviors postpartum, with further research needed in several areas. The first area to explore would be to validate the study findings with a larger sample. To better understand suicidal thoughts, further research is called for that use longitudinal designs to examine the relationships among coping approaches, suicidal ideations, and PPD. In addition, qualitative research studies will assist in better understanding the contextual factors that contribute to suicidal ideations postpartum. Another important topic for research is to explore the treatment of PPD to determine whether the effects of treatment in turn decrease suicidal ideations. Finally, bearing in mind that not all women who experience PPD inevitably have suicidal thoughts, future research should explore factors that promote resilience. Limitations In interpreting the substantive findings for this study, there are potential limitations that may preclude generalization of the study results. First, this study is limited by a small sample size, possibly causing the power to be too low to detect an acceptable level for significant effects. A second limitation is that we relied on a single self-reported question from the EPDS (Item 10) to represent suicidal ideations. Further, although this item is often used to report suicidal ideations, it may not reflect actual death intentions. Moreover, it has not been validated as a means to distinguish between groups in other research. Standardized measures for suicidal behaviors, such as the Scale for Suicide Ideation (SSI) 47 and the Suicidal Behaviors Questionnaire (SBQ-14) 48 should be used in future studies. Third, due to the limited number of variables that could be included in the statistical models (due to the small sample size) potential confounding could not be assessed. Finally, the dataset examined Clinical Medicine: Reproductive Health 2009:2 17

Doucet and Letourneau was cross-sectional, with data on all study variables collected once, simultaneously, thus precluding any causal inferences to be made. Nevertheless, this study provides valuable information and represents the first attempt to explore the impact of coping strategies on suicidal ideations among women who experience PPD. Conclusion Our findings suggest that coping mechanisms may be important predictors of suicidal ideations among women who experience PPD. In light of the high prevalence of suicidal ideations reported in this study, it is essential that postpartum women be monitored over time for potential suicidal thoughts or behaviors. Taking into consideration that emotion-focused coping was found to be protective towards suicidal ideations, while avoidance-focused coping and religious coping placed mothers at risk, these coping approaches should be explored in future prevention research studies. Suicidal behaviors are preventable health concerns. A clearer understanding of the relationship between the different approaches to coping and suicidal behaviors will assure that postpartum women receive the services and care they require to achieve optimal health. Acknowledgements Canadian Institutes of Health Research, co-investigators Drs. M. Stewart, K. Hegadoren, C. Rinaldi, C.L. Dennis, J. Stoppard, research assistants, and women who shared their experiences. Disclosures The authors report no conflicts of interest. References 1. O Hara MW, Swain AM. Rates and risk of postpartum depression: A metaanalysis. International Review of Psychiatry. 1996;8:37 54. 2. Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, et al. Perinatal depression: Prevalence, screening accuracy, and screening outcomes. (AHRQ Publication No. 05-E006-2). Rockville, MD: Agency for Healthcare Research and Quality. 2005 February. 3. Oates M. Suicide: The leading cause of maternal death. British Jorunal of Psychiatry. 2003;183:279 81. 4. 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