STRESS MEDICINE

Stress Med. 15, 103±107 (1999)

CORRELATES OF DEPRESSION AND PTSD IN

CAMBODIAN WOMEN WITH YOUNG CHILDREN:
A PILOT STUDY
STEPHEN MATTHEY1 MPsych*, DERRICK SILOVE2, MD, BRYANNE BARNETT3, MD,
MAUREEN H. FITZGERALD4, PhD, AND PENNY MITCHELL5, MPH
1Paediatric Mental Health Service South Western Sydney Area Health Service, Sydney, Australia
2
The School of Psychiatry, University of New South Wales; Psychiatry Research and Teaching Unit,
South Western Sydney Area Health Service, Sydney, Australia
3
The School of Psychiatry, University of New South Wales;
Paediatric Mental Health Service South Western Sydney Area Health Service, Sydney, Australia
4
The School of Occupational Therapy, University of Sydney, Sydney, Australia
5
Transcultural Mental Health Centre (NSW), Australia

SUMMARY
A self-selected sample of 31 Cambodian mothers in Australia were interviewed about their pre-migration experiences
and about childbirth. There was a signi®cant relationship between the number of trauma events experienced prior to
birth and psychological morbidity following birt`h. The Edinburgh Postnatal Depression Scale appears particularly
sensitive to detecting postnatal distress in these women, while there appears to have been no signi®cant bu€er e€ect
by the woman's social support network. While no causal model can be supported by this pilot study, there is a
suggestion that traumatic events experienced prior to birth may indicate that the woman is at risk for emotional
diculties postpartum. Copyright # 1999 John Wiley & Sons, Ltd.

KEY WORDS Ð postpartum depression; PTSD; migration

Psychosocial factors such as childhood adversity,
gender role con¯ict, inadequate social support,
current life stress and ongoing relationship di-
culties appear to in¯uence the onset and chronicity
of anxiety and depressive disorders in women with
young children.1±4 Immigrant women, especially
refugees, may be particularly vulnerable to such
stressors and hence at risk of ongoing a€ective
disturbance.
For example, Williams and Carmichael, in a
study of a multiethnic, inner urban community in
Melbourne, found that 41 percent of a sample of
recently arrived female immigrants were depressed,
a rate which was signi®cantly higher than that of
immigrants who had resided in Australia over a
longer period of time.5
Risk of current psychiatric disturbance is also
heightened for those immigrants and refugees who
*Correspondence to: Stephen Matthey, Paediatric Mental
Health Service, 13 Elizabeth Street, Liverpool 2170, NSW,
Australia. Tel: (02) 9827 8011. Fax: (02) 9827 8010. e-mail:
pmhs@unsw.ed.au
have experienced prior trauma,6 particularly when
post-migration experiences serve to trigger mem-
ories of such past events.7
Although the rate for depression is reported to
be rising in men, most surveys continue to report
higher rates in women, particularly those with
dependent children. For women there is also an
increased risk of developing psychiatric disturb-
ance during the ®rst year of parenthood. Kendell
reported a sixteen-fold increase in risk of being
admitted to a mental hospital in the ®rst 3 months
postpartum.8 Cox et al. reported a threefold
increase in the onset of depression within 5 weeks
of childbirth.9
While women with postnatal depression (PND)
have experienced the above risk factors, no investi-
gations have focused on a migrant community
which has experienced these risk factors and also
experienced major traumatic events in their own
country.
The Cambodians, like many refugee commun-
ities in western countries, not only have su€ered

CCC 0748±8386/99/020103±05$17.50 Received 30 October 1997

Copyright # 1999 John Wiley & Sons, Ltd. Accepted 2 March 1998
104 S. MATTHEY, D. SILOVE, B. BARNETT ET AL.
dislocation and cultural upheaval, but also the
ongoing psychological consequences of war, torture
and related human rights violations. Cambodian
women often were obliged to assume responsibility
for the family in the absence of husbands who
were killed, imprisoned or displaced. Some were
exploited in refugee camps, often having to accept
abuse in order to provide adequately for their
children.6
The procedures and pain of childbirth may
reawaken or exacerbate traumatic memories, and
the absence of family support, particularly the
woman's own mother and other female kin, may be
acutely felt in the early child-rearing period.
The present pilot study, undertaken on a
sample of Cambodian women who had given
birth in Australia over the previous year, aimed
to explore the possible relations among past
trauma, birth diculties, social supports and
severity of symptoms of anxiety, depression and
PTSD.
METHOD
Subjects
The subjects were Cambodian women who had
given birth in Australia during the previous year.
Women were recruited at hospitals and by word
of mouth in the Cambodian community. Thirty-
one Cambodian mothers were interviewed by
Cambodian members of the research team between
1 and 36 weeks postpartum. An equal number were
approached but declined to participate, with most
of the latter stating that they were free of any
diculties.
Procedure
The 31 Cambodian women were visited indivi-
dually in their homes where they completed the
Cambodian versions of the Hopkins Symptom
Checklist, a measure of anxiety and depression
(HSCL),10 the Harvard Trauma Questionnaire
(HTQ),11 a measure of past trauma exposure
and post-traumatic stress symptoms, and the
Edinburgh Postnatal Depression Scale (EPDS),12
a measure of distress speci®cally validated for
women in the perinatal period. This latter measure
was translated, back-translated and reviewed by
members of the team using the method of Brislin.13
Social support was assessed by asking subjects to
identify signi®cant others in their lives and to
Copyright # 1999 John Wiley & Sons, Ltd.
assign them to one of three concentric circles on a
diagram re¯ecting their degree of perceived close-
ness to the respondent.14,15 An open-ended semi-
structured interview was also administered, which
included questions concerning the woman's recent
birth experience, her history of other pregnancies
and births, and her pre-migration and migration
circumstances. Training was given to the Cambo-
dian interviewers to ensure reliable administration
of all measures. All interviews were conducted in
the Khmer language.
Clinical caseness (according to the HTQ
and HSCL) was ascertained by using the cuto€
scores determined by previous research.10,11
Scores on the EPDS were treated as continuous
since no cuto€ has been determined for the
Cambodian community for this instrument. Social
support was analysed in two ways Ð ®rstly by
summating the number of people included across
all three circles, and secondly by weighting the
number according to which circle the support
people were located in. Those in the closest circle
were weighted by a factor of 3, those in the second
circle by a factor of 2, and those in the third circle
by a factor of 1.
RESULTS
Subjects
The 31 women were aged between 21 and
39 years (M ˆ 28.3, SD ˆ 4.6), with all but four
being currently married.
The women had been resident in Australia from
less than 1 year to 14 years (M ˆ 4.9, SD ˆ 3.9),
with half having been in the country for less than
4 years. Fourteen had spent time in a refugee camp
before coming to Australia (most commonly a
camp in Thailand) and three had spent time in a
detention centre in Australia.
The youngest child ranged in age from 1 to
36 weeks (M ˆ 26 weeks). Nine mothers were
primiparae and, for the multiparae, the mean
number of additional children was three. Ten had
had a child born in Cambodia and 11 in a refugee
camp.
Symptom measures
In presenting the results, it should be remem-
bered that this is a self-selected sample, and that
while statistical analyses are presented, these should
not be interpreted to re¯ect the likely population
Stress Med. 15, 103±107 (1999)
 CORRELATES OF DEPRESSION AND PTSD IN CAMBODIAN MOTHERS
statistics. Only a large-scale epidemiological study
with a high uptake rate could provide this.
Fifteen of the sample (48 percent) scored above
the symptomatic cuto€ score on the HSCL (total),
while ®ve (16 percent) women scored in the PTSD
range on the HTQ. The mean EPDS score was 11.4
(SD ˆ 7.6), which is higher than for previous
samples of Anglo-Celtic women.12,16 The ®ve meet-
ing criteria for PTSD had a signi®cantly higher
EPDS score than the remainder (means: 17.8
versus 10.2; t(29) ˆ ÿ2.19, p ˆ 0.04).
The number of trauma categories experienced
or witnessed ranged from zero to 17 (M ˆ 8.7,
SD ˆ 4.9).
Statistically signi®cant associations ( p 5 0.05)
were found between the number of pre-migration
trauma categories experienced or witnessed and
measures of post-traumatic stress, anxiety and
depression, while the relationship with the EPDS
score was slightly weaker ( p ˆ 0.08) (Table 1).
Reports of adverse recent childbirth experiences
were associated with statistically elevated EPDS
scores only ( p 5 0.05).
Whether or not a woman had come to Australia
via a refugee camp or had had a child born in a
105
refugee camp were not associated with symptom
scores. Nor did the number of support people
predict the level of symptoms, whether analysed
using a summated support score or weighted
summated score. Also of note was the lack of a
relation between the length of time in Australia and
level of symptomatology.
Women were assigned to `caseness' if they
exceeded threshold scores for any one of the
HSCL or HTQ symptom scales. There was an
incremental increase in odds ratio for caseness with
increasing numbers of trauma events recorded
(Table 2). The highest odds ratio (11.9) was for
women reporting experiencing or witnessing ®ve
events or more.
DISCUSSION
The most striking ®nding was the relation between
the number of trauma categories witnessed or
experienced and levels of a€ective symptoms in
mothers. In particular, there appeared to be a
dose±response e€ect, with ®ve traumatic events
increasing the risk of caseness in relation to

Table 1 Ð Associations of pre- and post-migratory variables with psychological adjustment in Cambodian mothers
Variable Statistic HTQ SCL Ð SCL Ð EPDS
PTSD anxiety depression
No. of trauma events Spearman 0.57** 0.35* 0.37* 0.32
Refugee camp experience Mann-Whitney 74.5 77.5 99.5 97.0
Child born in camp Mann-Whitney 69.0 66.5 76.0 77.5
Social support{ Spearman} (0.04) (0.03) (0.06) (0.16)
Birth experience{ Mann-Whitney 82.0 74.0 84.5 42.5*
Time in Australia Spearman} 0.09 0.2 (0.02) (0.04)
* p 5 0.05; ** p 5 0.01. {Social support: summated weighting of number of people in the three-circle diagram (see text). {Birth
experience: reported experience of most recent birth (pleasant vs unpleasant). }Coecients in brackets are negative.

Table 2 Ð Relationship between exposure to traumatic events and caseness on the HSCL* and HTQ{ measures
Minimum no. of traumatic events Ratio of cases to Odds ratio 95% con®dence interval
experienced or witnessed non-cases{
2 19/30 0.37 0.23±0.59
3 19/30 0.37 0.23±0.59
4 19/28 0.32 0.19±0.55
5 17/22 11.9 1.9±76.5
6 14/19 3.9 0.84±18.2
7 13/18 3.0 0.68±13.6
8 11/15 2.8 0.61±12.4
* Hopkins Symptom Checklist (depression or anxiety). {Harvard Trauma Questionnaire (PTSD symptoms). {Those above/below
cuto€s on the HSCL or HTR for women experiencing or witnessing the speci®ed number of events.

Copyright # 1999 John Wiley & Sons, Ltd. Stress Med. 15, 103±107 (1999)
106 S. MATTHEY, D. SILOVE, B. BARNETT ET AL.
anxiety, depression or PTSD by a factor of
about 12.
The hypothesized refugee camp experiences and
a€ective symptoms were not supported, nor was
there an apparent bu€er e€ect for the index of
social support, in spite of the salience given to this
factor in the previous literature.17 Of interest also
was the lack of e€ect for length of time in Australia,
in contrast to the ®ndings of Williams and
Carmichael.5 It is possible that the crude index of
social support was inadequate, or that the level of
stress experienced was too high for available social
supports to ameliorate the e€ects.
Of note was that EPDS scores were selectively
elevated in those women reporting diculties in the
recent birth experience, and that scores were
unrelated to trauma exposure if alpha of 0.05 was
taken as the criterion. That the correlation
approached signi®cance ( p ˆ 0.08) may be inter-
preted as suggesting a possible relationship, or at
least that future investigations should not rule out
such a possibility. It is known that the traumatic
event of childhood sexual abuse may be a risk
factor for PND;18 it would seem probable therefore
that certain types of traumatic events experienced
by refugees may be vulnerability factors for PND.
The converse pattern emerged from the HTQ and
HSCL Ð statistically signi®cant associations with
past trauma but not with birth experiences. Such a
pattern lends support to the validity of the EPDS
as a measure which is especially sensitive to
emotional responses in the postpartum period,
and the notion that postpartum depression may be
distinguishable from other stress-related syn-
dromes.
Important limitations of the study include its
cross-sectional nature, the small sample size, the
modest response rate and potential biases in
recalling past trauma. That the women were
interviewed from 1±36 weeks postpartum is also a
limitation, in that relationships between the EPDS
and the independent variables might have been
evident if the usual screening time of 6±8 weeks
postpartum had been followed. Also, the low
uptake rate might well have biased the ®ndings.
Those who declined to participate might have been
women who had been in Australia for a long time
and did not want to discuss issues that would revive
painful memories. If this was the case, inclusion of
these women might well have given a di€erent
picture concerning some of the ®ndings Ð for
example, length of time in Australia might then
have been signi®cantly associated with level of
Copyright # 1999 John Wiley & Sons, Ltd.
current symptomatology, as found by Williams and
Carmichael,5 and associations between social
support and symptomatology might have become
evident. These are important conjectures to bear
in mind. Thus these ®ndings only relate to
Cambodian women who were prepared to discuss
issues surrounding pre- and post-migration experi-
ences. That half the women approached were not
willing to discuss such issues cautions against
generalizing our ®ndings to the larger Cambodian
community in Australia.
CONCLUSIONS
The present study provides pilot data suggesting a
link between pre-migration trauma and anxiety,
depression and PTSD symptoms in Cambodian
mothers. In contrast, EPDS scores appeared to
relate more speci®cally to dicult childbirth
experiences, with a weaker link to pre-migration
trauma experiences. Further research will be
necessary to con®rm the tentative ®nding that
prior trauma exposure and PTSD symptoms may
sensitize refugee women to increased risk of
symptoms of postpartum depression after child-
birth, and whether speci®c experiences make such
women more vulnerable.
ACKNOWLEDGEMENTS
We are grateful for the assistance of the following
team members in recruiting and interviewing the
women, and for advising the team on the cultural
aspects of the project: Vannak Ing, Tek Heang Ya,
Sim Heang Hay, Thida Yang and Hong Ly Duong.
The study was funded by the Transcultural
Mental Health Centre (NSW).
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