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The Structure of Women's Mood in the Early Postpartum

Melissa M. Buttner, Michael W. O'Hara and David Watson Assessment 2012 19: 247 originally published online 6 December 2011 DOI: 10.1177/1073191111429388 The online version of this article can be found at: http://asm.sagepub.com/content/19/2/247

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91111429388Buttner et al.Assessment The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav

ASM19210.1177/10731

The Structure of Womens Mood in the Early Postpartum

Melissa M. Buttner1, Michael W. OHara1, and David Watson2

Assessment 19(2) 247256 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1073191111429388 http://asm.sagepub.com

Abstract The postpartum blues is a mild, predictable mood disturbance occurring within the first several days following childbirth. Previous analyses of the blues symptom structure yielded inconclusive findings, making reliable assessment a significant methodological limitation. The current study aimed to explicate the symptom structure of womens mood following childbirth, and to examine psychometric properties of the Daily Experiences Questionnaire (DEQ), an adapted version of the Kennerley Blues Questionnaire that included additional items from the Positive and Negative Affect Schedule. Mothers who recently delivered (N = 216) were recruited from a university hospital and asked to complete mood ratings on six consecutive days using the DEQ. Exploratory factor analysis yielded an interpretable two-factor solution identified as Negative Affect and Positive Affect. Scale reliability indices were excellent, with a high level of agreement in factor structure over time. This two-factor model provides reliable assessment of womens mood in the early postpartum, informing the study of reproductive-related mood disorders. Keywords postpartum blues, factor analysis, positive and negative affect, perinatal mental health The postpartum blues is often characterized as a mild mood disturbance linked to childbirth that occurs within the first 7 to 10 days after delivery (Harris et al., 1994; Iles, Gath, & Kennerley, 1989). Because there are no agreed on criteria for the postpartum blues, prevalence rates range from 26% to 84%, reflecting more (OHara, Schlechte, Lewis, & Wright, 1991) or less (Oakley & Chamberlain, 1981) stringent criteria. The etiology of the postpartum blues is not well-understood, but it is commonly believed to have a biological basis due to the abrupt withdrawal of ovarian hormones following childbirth, in particular estradiol and progesterone (e.g., Bloch, Daly, & Rubinow, 2003; Glover & Kammerer, 2004). This very abrupt change in the reproductive hormonal milieu may produce perturbations in mood that are relatively unique compared with other periods of hormonal changes, such as menstruation (Glover & Kammerer, 2004). More specifically, estradiol levels by the end of pregnancy are as much as 50 times the maximum menstrual cycle level and return to early follicular levels by Day 3 postpartum. Furthermore, progesterone levels increase by 10 times the highest menstrual cycle levels by the third trimester and typically normalize to follicular levels between postpartum Days 3 to 7 (Bloch et al., 2003; Nappi et al., 2001). Sacher et al. (2010) found a link between lowered estrogen levels during the first 3 to 4 days postpartum and MAO-A (monoamine oxidase A) synthesis, identifying elevated MAO-A levels in the early postpartum period as a marker for a monoamine-lowering process that may contribute to the mood dysregulation characteristic of the postpartum blues. Moreover, these researchers showed that MAO-A binding was highest on Day 5 postpartum, the day most strongly associated with a peaking phenomenon across studies of postpartum blues (e.g., Harris et al., 1994). Emotional lability appears to be a hallmark of the postpartum blues and is characterized by symptoms reflecting abrupt changes in mood and emotion as well as characteristics such as having up and down mood and being overly sensitive (Ballinger, Buckley, Naylor, & Stansfield, 1979; Kendell, McGuire, Connor, & Cox1981; OHara, 1995). Timing of symptoms is critical, potentially informing the etiologic biological underpinnings of the postpartum blues. A peaking phenomenon has been identified as highly characteristic of the blues syndrome, with most evidence to suggest that negative mood symptoms are at their most intense between 3 and 5 days after delivery (e.g., Gonidakis, Rabavilas, Varsou, Kreatsas, & Christodoulou, 2007; Harris et al., 1994; OHara, 1995); other researchers have shown a peak in mood between 4 and 6 days postpartum (e.g., Stein, 1980).
1 2

University of Iowa, Iowa City, IA, USA University of Notre Dame, Notre Dame, IN, USA

Corresponding Author: Michael W. OHara, Department of Psychology, University of Iowa, Iowa City, IA 52242, USA Email: mike-ohara@uiowa.edu

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248 Despite the relatively mild clinical course of the postpartum blues, it may reflect a vulnerability to reproductiverelated mood disorders. For example, the postpartum blues has been linked to later postpartum depression (e.g., Henshaw, Foreman, & Cox, 2004; OHara et al., 1991; Reck, Stehle, Reinig, & Mundt, 2009; Watanabe et al., 2008). Additionally, women who experience premenstrual symptoms are at increased risk for the postpartum blues (Bloch, Rotenberg, Koren, & Klein, 2005; Henshaw et al., 2004; OHara et al., 1991). These findings underscore the importance of understanding the etiology and characteristics of symptom expression in the postpartum blues as well as the possibility that there is a unique structure to mood in the early postpartum period. Although it may potentially inform both research and clinical work in the area of womens mental health, existing research on the postpartum blues has important methodological limitations. These limitations include the use of nonspecific measures to assess the blues syndrome. More specifically, research has relied on a variety of measures to assess the blues syndrome, including visual analogue scales (Kendell et al., 1981), adjective checklists, and rating scales designed to measure symptoms of depression, such as the Beck Depression InventoryI (Handley, Dunn, Waldron, & Baker, 1980) and the Edinburgh Postnatal Depression Scale, a specific measure of postpartum depression (Hannah, Adams, Lee, Glover, & Sandler, 1992). These measures have significant limitations, including (a) failure to address the full range of womens affective symptoms, (b) poor design for daily administration, and (c) inadequate psychometric validation in the context of the postpartum blues (Henshaw, 2003). Early investigators of the postpartum blues developed scales by selecting items based on clinical descriptions of womens emotional experiences following childbirth, a rationalrather than a factor analyticapproach. In general, this strategy yielded one-factor solutions (e.g., Pitt, 1973; Yalom, Lunde, Moos, & Hamburg, 1968). Whiffen (1988) conducted a principal components analysis to evaluate the coherence of blues symptoms identified in previous research. In this study, participants (N = 124) were asked to rate the severity of 15 symptoms retrospectively on a 7-point scale on Day 11 postpartum. Through this process, a four-component solution emerged, accounting for 62.1% of the variance. The components were labeled (a) Maternity Blues, (b) Tension, (c) Cognitive Impairment, and (d) Blues Attributions. However, these findings should be interpreted with caution, given the use of a small item pool and retrospective mood ratings in scale development. Kennerley and Gath (1989) employed a cluster analytic technique to develop the Kennerley Blues Questionnaire (KBQ). The original item pool in this scale development process consisted of 47 different adjectives describing womens emotional experiences during the first few days

Assessment 19(2) following childbirth. Findings from the cluster analysis yielded seven clusters: Primary blues, Decreased alertness, Hypersensitivity, Decreased self-confidence, Depression, Despondency, and Reservation (Kennerley & Gath, 1989). Research findings on mood in the early postpartum period suggest that its structure may be more complex than mood at other times in a womans life (e.g., Kennerley & Gath, 1989; Whiffen, 1988). This is significant because it has implications for the assessment of mood symptoms in the early postpartum period and suggests that there is something unique about a womans experience during this time that goes beyond the adjustments of being a new mother. Within the general mood literature, structural analyses consistently have identified two varimax-rotated factors defined as Positive Affect (PA) and Negative Affect (NA; Watson & Tellegen, 1985). PA is defined by mood items such as enthusiastic, active, and alert, whereas NA is characterized by descriptors such as angry, disgusted, guilty, and afraid (Watson, Clark, & Tellegen, 1988). These two symptom dimensions are widely used in the self-report mood literature to model affect (Watson et al., 1988) and may extend to womens affective experiences in the early postpartum as well. In the present study, exploratory factor analysis (EFA) was used to examine the underlying symptom structure of the blues and to assess the psychometric properties of the Daily Experiences Questionnaire (DEQ), a modified and expanded version of the KBQ. To determine the stability of the most interpretable and meaningful factor solution, factor comparability analyses were conducted by comparing models derived on the first 6 days of the study assessment period; we also examined the replicability of the factor loadings via congruence coefficients. Although we collected data on 10 consecutive evenings, postpartum Day 6 was selected as a cutoff based on previous research suggesting that the peaking phenomenon, highly characteristic of the blues, occurs between postpartum Days 3 and 5 (e.g., Gonidakis et al., 2007; Harris et al., 1994; Kendell, Mackenzie, West, McGuire, & Cox, 1984), and that the blues remit around Day 10 (Stein, 1980).

Method Participants
Eligible mothers (N = 216) spoke English and were between the ages of 18 and 45 years. Mothers were included in the study regardless of birth complications, number of days spent on the maternity unit, and method of delivery to ensure a wide range of symptoms. The majority of mothers did not endorse any birth complications (76%); reported birth complications were blood loss requiring medication/ transfusion (4%), significant tearing or stitches (10%), infection (2%), and other (8%). Vaginal delivery was most

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Buttner et al. common (70%), with 30% delivering via cesarean section/ other method. Participants were, on average, 28 years old (SD = 5.6) and college educated (M = 15.0 years, SD = 2.9). Approximately 80% of the participants were Caucasian, 75% were breastfeeding at time of entry into the study, and approximately 70% were married. More than half of the participants were working (61.1%) and roughly half (49.9%) had an annual income equal to or greater than $40,000. The number of participants completing mood assessments for each postpartum day reported in these analyses ranged from N = 123 to N = 172 (Day 1, N = 172; Day 2, N = 130; Day 3, N = 123; Day 4, N = 130; Day 5, N = 127; and Day 6, N = 126); 75 participants (35%) completed ratings on all 6 days. Ten participants (7%) were experiencing a major depressive episode at time of completing the Day 1 mood assessment.

249 Gath, 1989). We expanded the original 28-item Kennerley scale (one item, depression, was inadvertently left off the original Kennerley scale; thus, 27 items from the scale were included in our item pool) to include 10 items from the PANAS (Positive and Negative Affect Schedule; Watson et al., 1988), and one item to assess loss of appetite. Because of minimal representation of positive mood descriptors in previous measures of the postpartum blues (e.g., Kennerley & Gath, 1989; Stein, 1980), we included six positive mood items (active, determined, enthusiastic, inspired, interested, and proud) from the PANAS in our item pool. To maximize representation of NA-related mood descriptors, we also included four negative mood descriptors (afraid, ashamed, guilty, and hostile) from the PANAS. Finally, we included the item loss of appetite because of its relation to depression and variability in the postpartum period (Stein, 1980). Each item was rated (similar to the PANAS) on a 1 to 5 Likert-type scale ranging from 1 (very slightly or not at all) to 5 (extremely), reflecting the mothers affective experience on that day.

Procedures
On receiving approval from the University of Iowas Institutional Review Board, mothers who recently delivered were recruited from the maternity unit at the University of Iowa Hospitals and Clinics on postpartum Day 0, 1, or 2. Postpartum Day 1 was defined as beginning at 12:01 a.m. on the first day after childbirth. Recruiters approached mothers meeting inclusion criteria (English speaking and 18 years or older) and asked for their participation in a research study that examined womens emotional experiences following childbirth. Recruiters explained the study protocol and reviewed the consent form with interested participants; on receiving informed consent, recruiters asked participants to complete three brief questionnaires: (a) Demographic Questionnaire, (b) Mood Variability Questionnaire, and (c) the DEQ. Participants were given the option to complete the daily mood ratings either online (60% of participants) or over the telephone (40%) with a researcher between the hours of 5 p.m. and 8 p.m. If this was not possible, participants were asked to complete the questionnaire before bedtime that evening or by noon the following day. If 1 day was missed, participants were instructed to complete two questionnaires (one for the missed day and one for the current day) in the evening of the following day. Online questionnaires were completed using a web-based survey application offered to researchers by The University of Iowa.

Data Analyses
EFA was conducted using the principal axis factoring extraction method, with varimax (orthogonal) rotation, to factor analyze the daily mood ratings from the DEQ. Separate analyses were conducted on each of the first 6 days of the postpartum period. EFA was selected for factor analysis and for the examination of the basic psychometric properties of the DEQ because it is designed for exploring a data set with limited theoretical basis for specifying a priori the number and patterns of common factors (Costello & Osborne, 2005; Floyd & Widaman, 1995). A parallel analysis (Horn, 1965; OConnor, 2000) was performed to identify the appropriate number of factors for extraction. The initial solution derived on postpartum Day 1 was then validated using factor comparison analyses based on two different approaches: coefficients of congruence (Tucker, 1971) and comparability coefficients derived from factor scores (Gorsuch, 1983). Postpartum Day 1 data were used to run the EFA because it represented the largest sample size (N = 172) over the 6-day assessment period.

Results Exploratory Factor Analysis

Factor retention. Parallel analysis (OConnor, 2000) for the 95th percentile in 1,000 random data sets identified 4 factors as the maximum number of meaningful dimensions. At root 5, the eigenvalue (1.58) fell below the mean random data eigenvalue (1.64), indicating that the fifth factor was modeling error variance. Thus, we considered four factors a maximum and examined two-, three-, and four-factor

Measures
Demographic Questionnaire. Information was collected on participants age, education, income, marital status, and breastfeeding status, as well as parity and method of delivery. Daily Experiences Questionnaire. The DEQ (see the appendix) is a 38-item scale adapted from the KBQ (Kennerley &

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250
Table 1. Congruence Coefficients across Postpartum Days 1 to 6 for Negative Affect and Positive Affect Factors Postpartum day 1. Day 1 2. Day 2 3. Day 3 4. Day 4 5. Day 5 6. Day 6 1 .99 .99 .99 .99 .99 2 .99 .99 .99 .99 .99 3 .99 .98 .99 .99 .99 4 .99 .99 .99 .99 .99 5 .99 .99 .99 .99 .99 6 .99 .99 .99 .99 .98

Assessment 19(2)
Table 2. Comparability Correlations across Postpartum Days 1 to 6 for the Negative Affect and Positive Affect Factors Postpartum day 1. Day 1 2. Day 2 3. Day 3 4. Day 4 5. Day 5 6. Day 6 1 .98 .98 .99 .99 .99 2 .98 .98 .99 .98 .99 3 .99 .99 .99 .99 .99 4 .98 .98 .98 .99 .99 5 .99 .98 .98 .99 .99 6 .99 .98 .98 .99 .99

Note. N = 38. Coefficients for negative affect are presented above the diagonal. Coefficients for positive affect are presented below the diagonal.

Note. These correlations were computed using the Day 1 responses (N = 172); see text for details. Correlations for negative affect are presented above the diagonal. Correlations for positive affect are presented below the diagonal.

solutions. In examining the loadings and the number of items with high cross-loadings in the two-, three-, and fourfactor solutions, it appeared that the two-factor solution yielded the most distinguishable set of factors with meaningful content; these dimensions could be identified as NA and PA, respectively. In the two-factor solution, there were relatively few items with cross-loadings greater than |.40|, compared with the three- and four-factor solutions, suggesting a clear delineation between these two dimensions. The three- and four-factor solutions yielded additional redundant factors, tapping variations of NA and PA. Additionally, we reran the analyses using an oblique promax rotation and obtained results very similar to those generated using varimax rotation. Factor similarity. Two sets of analyses were conducted to provide a quantitative comparison of the factor structures of NA and PA across the first 6 days of the assessment period. Additionally, we conducted analyses of factor similarity for the three- and four-factor solutions discussed previously to ensure that these models did not enhance the overall quality of the structure beyond two factors. A well-established method of factor comparison is computing the coefficient of congruence (Tucker, 1971; Wrigley & Neuhaus, 1955). Congruence coefficients are based on a comparison of factor loadings between solutions and provide a measure of the similarity of the factor-loading matrices in these solutions. Factor comparisons based on the coefficient of congruence method are common in the literature on scale development and appropriate for determining the replicability of a factor solution (Cordano, Scherer, & Owen, 2003). According to Tucker (1971), a coefficient of 1.0 suggests perfect agreement between two factors being compared, whereas a coefficient of 0 represents no agreement. More specifically, a coefficient greater than .90 is indicative of congruent factors, and less than .45 suggests no agreement (Tucker, 1971). These coefficients ranged from .98 to .99 for each of the factors in the two-factor solution (i.e., NA and PA), suggesting a high level of agreement in the replicability of the factor structure over the assessment period (see Table 1).

Comparability coefficients also were computed. In these analyses, regression-based factor scoring weights are calculated separately for each factor on each postpartum day. These weights are then multiplied by each participants standardized responses to produce an overall score for each person on each factor on each day. The weights derived from one solution then can be applied to others, yielding multiple scores for each factor (one based on the weights from each of the solutions) that are then correlated within the same data set; in this case, we computed these comparability correlations using the Day 1 data, which had the largest sample size (N = 172). The comparability correlations based on the two-factor model ranged from .98 to .99 for each of the factors (NA and PA) across the 6 postpartum days, a pattern similar to that found in the coefficient of congruence analyses (see Table 2). Additionally, the three- and four-factor solutions derived on postpartum Day 1 were compared with solutions found on postpartum Days 2 through 6. The third factor in the three-factor solution (not shown) accounted for an additional 10.2% of the variance; in this solution, PA dimension split apart with markers of concentration and energy forming a third factor. Thus, these findings yielded a modified version of the two-factor solution, with a dimension identified as Energy emerging as a third factor. Congruence coefficients for the three-factor solution suggested a high degree of similarity for the NA (.93 to .97) and PA (.99) factors; however, the coefficients for the Energy factor (.01 to .94) indicated that it was not strongly replicable across days. Similarly, comparability correlations for NA (.69 to .97) and PA (.95 to .99) showed good to excellent factor similarity over time, whereas correlations for the Energy factor (.05 to .94) indicated that it did not replicate over time, consistent with findings based on congruence coefficients. The fourth factor in the four-factor solution (not shown) accounted for an additional 6.1% of the variance; in this solution, markers of both NA and PA split off to form two hybrid factors. Some markers of NA (e.g., up and down in mood, irritable, crying) split to form a third dimension, which we identified as a Blues factor. Similarly, some

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Buttner et al. markers of PA (e.g., alert, active, able to concentrate) split to form a fourth dimension identified as Energy, similar to the Energy dimension identified in the three-factor solution. The congruence coefficients based on the four-factor solution suggested that the factors representing NA (.60 to .97), PA (.96 to .99), and the Blues (.91 to .97) were congruent and replicated over time, whereas coefficients for the Energy factor (.12 to .90) indicated that it was not consistently replicable across the study period. Findings based on comparability correlations were somewhat consistent, with correlations for PA (.95 to .99) and the Blues (.63 to .97) suggesting good agreement in factor similarity over time. In contrast, correlations for NA (.02 to .90) and Energy (.01 to .92) showed little to no support for replication of the four-factor structure over time. The factor similarity data for the two-factor solution provided a clear contrast to the three- and four-factor solutions. The two-factor solution yielded factors that were clearly delineated and highly replicable, a sharp contrast to the three- and four-factor solutions that yielded smaller dimensions (Energy and the Blues) that were relatively unstable over time. Thus, we concluded that the three- and fourfactor solutions did not enhance the overall structure beyond the first two dimensions, and adopted the two-factor solution as the final model. Polychoric analyses. Because items do not have normal distributions, an alternative approach to item-level factor analysis is to use polychoric correlation matrices; polychoric correlations are estimates of what the Pearson correlations would be had the items been normally distributed (HolgadoTello, Chacn-Moscoso, Barbero-Garca, & Vila-Abad, 2010). To examine this as a potential consideration in the current data analyses, a polychoric EFA was run using Mplus (Version 6.1). The results were highly consistent with the original two-factor solution identified using Pearson correlations (see Table 3). More specifically, the EFA based on polychoric correlations supported a clear two-factor solution identified as NA and PA (see Table 4). The root mean square error of approximation (RMSEA) estimate was .05 and the value for the root mean square residual (RMSR) was .09. Suggested cutoff values for incremental fit indices that represent acceptable lower bounds of good model fit are .08 for RMSEA and .10 for the RMSR (Vandenberg & Lance, 2000). Additionally, the initial solution derived on postpartum Day 1 using polychoric interitem correlation matrices was validated by computing coefficients of congruence with the two Pearson correlation-based factors; as previously discussed, congruence coefficients are a well-established method of factor comparison (Tucker, 1971; Wrigley & Neuhaus, 1955). These coefficients were .98 or greater for both factors in the two-factor solution (NA and PA). Thus, the same two factors emerged, regardless of whether Pearson correlations or polychoric correlations were used in the

251
Table 3. Pearson CorrelationBased Factor Loadings of Items from the Daily Experiences Questionnaire Item Up and down in mood Mentally tense Overemotional Oversensitive Brooding Low spirited Tearful Irritable Helpless Guilty Crying without being able to stop Feeling sorry for yourself Ashamed Afraid Changeable in your spirits Restless Anxious Loss of appetite Forgetful, muddled Hostile Finding it difficult to show feelings Tired Emotionally numb Wishing you were alone Inspired Confident Lively Enthusiastic Interested Alert Determined Calm, tranquil Active Proud Happy Able to concentrate Elated Mentally relaxed Negative Affect .82 .72 .70 .68 .67 .62 .62 .61 .58 .58 .58 .55 .55 .53 .53 .48 .47 .46 .43 .43 .40 .34 .34 .27 .08 .31 .07 .20 .17 .15 .02 .29 .02 .23 .42 .22 .22 .41 Positive Affect .13 .27 .04 .10 .17 .27 .17 .21 .32 .24 .16 .23 .18 .18 .13 .05 .06 .09 .27 .02 .11 .19 .19 .17 .72 .72 .71 .67 .65 .64 .63 .63 .60 .59 .59 .59 .47 .43

Note. N = 172 (Postpartum Day 1). Item loadings meeting criteria as a marker for each factor are in boldface. Criteria for Pearson correlations are |.40| on the primary factor and |.30| on the secondary factor.

EFAs. These findings also are consistent with our original factor similarity analyses using Pearson correlation matrices and suggest a very high level of agreement in the replicability of the factor structure over the 6-day assessment period. Scale creation. Given that these two approaches clearly yielded very similar results, we used the original Pearsonbased factors to create scales. In creating scales based on

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252
Table 4. Polychoric CorrelationBased Factor Loadings of Items from the Daily Experiences Questionnaire Item Up and down in mood Mentally tense Overemotional Oversensitive Brooding Low spirited Tearful Irritable Helpless Guilty Crying without being able to stop Feeling sorry for yourself Ashamed Afraid Changeable in your spirits Restless Anxious Loss of appetite Forgetful, muddled Hostile Finding it difficult to show feelings Tired Emotionally numb Wishing you were alone Inspired Confident Lively Enthusiastic Interested Alert Determined Calm, tranquil Active Proud Happy Able to concentrate Elated Mentally relaxed Negative Affect .90 .76 .83 .79 .71 .72 .74 .69 .65 .72 .79 .69 .77 .59 .63 .52 .55 .50 .48 .65 .56 .40 .54 .33 .08 .34 .12 .23 .17 .18 .01 .33 .03 .25 .46 .23 .26 .46 Positive Affect .12 .37 .01 .06 .29 .43 .13 .20 .47 .45 .29 .38 .39 .20 .11 .07 .08 .11 .29 .05 .25 .19 .34 .20 .77 .73 .76 .71 .73 .68 .72 .64 .66 .69 .68 .58 .52 .46

Assessment 19(2)
Table 5. Varimax-Rotated Factor Loadings of Items in Final Scales from the Daily Experiences Questionnaire Item Up and down in mood Mentally tense Overemotional Oversensitive Brooding Low spirited Tearful Irritable Guiltya Crying without being able to stop Feeling sorry for yourself Ashameda Afraida Changeable in your spirits Restless Anxious Loss of appetite Forgetful, muddled Hostilea Finding it difficult to show feelings Inspireda Lively Enthusiastica Interesteda Alert Determineda Calm, tranquil Activea Prouda Able to concentrate Elated Negative Affect .82 .72 .70 .68 .67 .62 .62 .61 .58 .58 .55 .55 .53 .53 .48 .47 .46 .43 .43 .40 .08 .07 .20 .17 .15 .02 .29 .02 .23 .22 .22 Positive Affect .13 .27 .04 .10 .17 .27 .17 .21 .24 .16 .23 .18 .18 .13 .05 .06 .09 .27 .02 .11 .72 .71 .67 .65 .64 .63 .63 .60 .59 .59 .47

Note. N = 172 (Day 1). Items loading on each factor are in boldface. Ratings were made on a 5-point scale (1 = very slightly or not at all, 5 = extremely). a. Items from the Positive and Negative Affect Schedule.

Note. N = 172 (Postpartum Day 1). Item loadings meeting criteria as a marker for each factor are in boldface. In moving to polychoric interitem correlation matrices, we adjusted our original criteria upward to determine markers on each of the factorsusing |.50| or greater on the primary factor and less than |.40| on the secondary factor (Note: In our original analyses, we used |.40| on the primary factor and |.30| on the secondary factor)because polychoric correlations and factor loadings tend to be higher, relative to Pearson correlations and factor loadings (Holgado-Tello et al., 2010).

the two-factor solution, an item was considered a marker for that particular scale if it had a loading of |.40| or greater on the primary factor and a loading less than |.30| on the secondary factor in the Day 1 ratings. Using these criteria,

items that did not clearly load on either factor were dropped from the analyses. A total of seven items were subsequently dropped from the scales. The following four items were removed from Factor 1: helpless, emotionally numb, tired, and wishing you were alone; the following three items were removed from Factor 2: confident, happy, and mentally relaxed. After removing the seven items from the original item pool, a total of 31 items were included in the two scales (see Table 5 for item content and loadings). The first scale was labeled NA, reflecting symptoms of low mood, crying, and mood lability, and was composed of 20 items. The second scale was labeled PA, reflecting a sense of enthusiasm and feeling lively and engaged in life and consisted of 11 items. The mood ratings on this reduced set of 31 items were again subjected to a principal factor analysis with

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Buttner et al.
Table 6. Basic Scale Characteristics for the Daily Experiences Questionnaire Negative affect (NA) Day 1 2 3 4 5 6 N 172 130 123 130 127 126 M 30.63 32.84 33.29 33.88 40.72 33.16 SD 10.45 11.95 12.08 12.24 13.19 13.60 Positive affect (PA) M 34.87 34.11 34.40 32.85 30.11 32.79 SD 8.48 9.06 9.46 8.70 8.55 9.70 NA .91 .92 .92 .92 .92 .94 PA .88 .89 .91 .90 .91 .92 NA AIC .35 .37 .38 .38 .39 .44 PA AIC .41 .43 .48 .44 .49 .39

253

NAPA intercorrelation .42 .37 .49 .40 .39 .31

Note. = Cronbachs alpha; AIC = average interitem correlation.

varimax rotation to ensure that all items on the two scales had factor loadings of |.40| or greater on the primary factor, and no cross loadings greater than |.30| on the secondary factor (see Table 5); these two factors accounted for 40.8% of the variance. Scale characteristics. Internal consistency reliabilities (Cronbachs coefficient alpha and average interitem correlations [AICs]), and scale intercorrelations were computed for NA and PA scales on postpartum Days 1 to 6, and are presented in Table 6. The alpha reliabilities are consistently strong for both scales, with coefficients ranging from .91 to .94 for NA and from .88 to .92 for PA. According to Clark and Watson (1995), an AIC for a scale in the moderate range (.15 to .50) reflects an appropriate level of internal consistency within the items. The AICs for both scales fell within this range. The AICs across days for NA ranged from r = .35 to r = .44; those for PA ranged from r = .39 to r = .41, which again illustrates the stability of the two-factor solution across days. The correlations between the NA and PA scales across days ranged from r = .31 to r = .49, which was in the expected range given the item content of these scales (Watson & Clark, 1997; Watson & Tellegen, 1985).

showed that the strongest loadings on the PA scale were associated with positive mood items extracted from the PANAS, indicating that positive mood descriptors (e.g., inspired, enthusiastic) may play an important role in the characterization of womens mood following childbirth. Finally, factor similarity analyses confirmed that the same two-factor structure emerged across 6 consecutive days following delivery, supporting the stability of the two-factor model over time.

Comparison With Previous Studies

Previous studies examining the symptom structure of the blues have relied on rational or structural analytic approaches to scale development. Using a rational approach, scales were developed using affect-related mood descriptors elicited by newly delivered mothers. This approach generally yielded one-factor solutions (e.g., Handley et al., 1980). Previous investigators have also relied on structural approaches, including principal components (Whiffen, 1988) and cluster analytic techniques (Kennerley & Gath, 1989). Although these techniques are considered acceptable for scale development, methodological issues, such as small sample size and retrospective mood ratings (Whiffen, 1988) and lack of reliability indices and replication data (Kennerley & Gath, 1989) raise concerns about the stability, comprehensiveness, and accuracy of these models. Therefore, it is difficult to generate conclusions on how symptoms relate to each other and the extent to which the blues serve as a reliable predictor of clinically significant disorders. In contrast to previous studies on scale development, the current study used EFA with principal axis factoring, a robust and well-established data reduction method (Floyd & Widaman, 1995), to establish a two-factor solution of NA and PA as having the best fit for modeling the final 31 items on the DEQ. Multiple mood assessments in the present study also facilitated a rigorous examination of the structure of womens emotional experiences (Hedges, Jandorf, & Stone, 1985) during the early postpartum, and allowed for factor comparisons between different days of sampling

Discussion Main Findings

This study addressed methodological issues with using current nonspecific measures to assess the blues, including (a) failure to capture the full range of affect-related mood descriptors, both negative and positive, experienced by recently delivered mothers; (b) poor design for daily administration; and (c) inadequate psychometric validation in the context of the blues. Thus, we developed a more comprehensive measure of the blues for daily administration, with additional items tapping PA and NA. EFA was employed in this study and yielded a two-factor solution that was identified as having the best fit for modeling the final 31 mood items on the DEQ, with a clean split between two symptom dimensions, NA and PA. Notably, our findings

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254 using the coefficient of congruence and comparability coefficients methods (Teel & Verran, 1991; Tucker, 1971; Wrigley & Neuhaus, 1955). Earlier structural-analytic studies did not include multiple assessments and did not examine the replicability of the factor structure of postpartum mood over time (Kennerley & Gath, 1989; Whiffen, 1988). Previous research findings suggest that there is a distinct cluster (Kennerley & Gath, 1989) or component (Whiffen, 1988) representing the blues syndrome. In the current study, the classic symptoms (e.g., up and down in mood, crying, low spirited) forming the Primary blues cluster identified by Kennerley and Gath (1989) showed moderate to strong loadings on the NA factor, suggesting these items are (a) cohesive and (b) substantially linked to other types of negative mood. Moreover, factor-similarity analyses based on three- and four-factor solutions (which included a Blues factor) showed a poor level of replicability in the factor structure over time. In sum, there was little support for a separate Blues factor in the present study.

Assessment 19(2) assessment. The presence of depression at time of mood assessment may have potentially inflated the report of negative mood and/or diminished report of positive mood. Finally, as noted earlier, the depression item was inadvertently left off the DEQ. Nevertheless, even without this item, the NA factor was clearly defined by 20 negative mood descriptors with strong loadings and weak crossloadings.

Implications and Future Research

This is the first study to employ a well-established and robust data reduction method, EFA with principal axis factoring, to examine the psychometric properties and underlying factor structure of a postpartum blues measure, the DEQ. The DEQ is brief and suitable for daily administration, with strong psychometric properties that support its use as a reliable measure to assess womens emotional experiences following delivery. A two-factor model identified as NA and PA was determined to have the best fit for modeling the 31 items on the DEQ, consistent with the two-factor model of affect found in the general mood literature (Watson et al., 1988; Watson & Tellegen, 1985). This suggests that the structure of womens mood during the first week after delivery is no different than at other times outside the early postpartum, and that womens mood is not affected by the process of hormonal normalization suggested in previous research (Glover & Kammerer, 2004). Additionally, our findings lend support for the role of positive mood descriptors in the characterization of womens mood following delivery. Fluctuations in positive mood potentially are important and should not be overlooked; existing blues measures do not provide adequate representation of positive mood items (Handley et al., 1980; Kennerley & Gath, 1989; Stein, 1980). Future research should include replication studies using the DEQ to model NA and PA and to examine the invariance of the two-factor model before, during, and after approximately 2 weeks postpartum to determine whether this widely used model of general affect generalizes to the postpartum period as well. Because it is important to improve understanding into the etiologic biological correlates of the postpartum blues, it is worthwhile to examine potential correlates using the DEQ. In addition, it may be worthwhile to use the DEQ to assess mood in a recently delivered population with complex mood descriptors removed from the scale (e.g., ashamed, enthusiastic, inspired), to determine if the two-factor structure replicates. Finally, mood monitoring throughout the day using the DEQ rather than simply at the end of the day has the potential to capture a great deal more mood variability in recently delivered women (Hedges et al., 1985). A sampling technique, such as ecological momentary assessment (Stone & Shiffman, 1994) may be beneficial in future research as it would allow for reporting of symptoms in close proximity to the actual experience.

Limitations
Our study had some limitations. We relied on relatively small sample sizes (e.g., postpartum Day 1, N = 172; Day 2, N = 130) for conducting EFA, which may potentially affect the generalizability of the results. However, the very strong level of factor similarity we observed across the 6 days mitigates this concern to a considerable extent (Hogarty, Hines, Kromrey, Ferron, & Mumford, 2005). Furthermore, our sample was primarily Caucasian (80%) and roughly half (49.9%) reported an annual income of greater than or equal to $40,000. Thus, replication of the current findings is needed in more diverse samples. There also was a high rate of attrition in this study. The total sample size for each postpartum day reported on in this study ranged from N = 123 to N = 172, with a total of 216 women enrolled in the study. It was revealed through discussions with participants that remembering to complete questionnaires daily was burdensome, especially while caring for a newborn. However, only a small proportion of mood ratings (7%) were completed at times outside of protocol (e.g., after 8 p.m. or on the following day). Thus, adherence to study protocol was minimally compromised. Women were asked to complete the DEQ on a daily basis between the hours of 5 p.m. to 8 p.m., reflecting on their mood over the entire day when responding to each of the items on the questionnaire. It is possible that assessing mood at a different time of the day or asking about mood at the time of the rating specifically would have yielded different results. However, the approach we used represents standard protocol in the mood literature (e.g., Watson et al., 1988) and provides an overall representation of womens mood throughout the day. Another limitation is that 7% of the women (N = 10/148) were experiencing a major depressive episode at time of completing the Day 1 mood

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Appendix Original Items Comprising the Daily Experiences Questionnaire (DEQ)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. Crying without being able to stop Mentally tense Able to concentrate Low spirited Elated (extremely happy and excited) Helplessa Alert Finding it difficult to show your feelings Forgetful, muddled Mentally relaxeda Wishing you were alonea Proudb Emotionally numb, without feelingsa Feeling sorry for yourself Inspiredb Brooding on things (thinking a long time about things that make you sad, worried, or angry) Activeb Overemotional Happya Changeable in your spirits Anxious Tireda Confidenta Irritable Lively Oversensitive Tearful Up and down in mood Restless Calm, tranquil Guiltyb Interestedb Hostileb Determinedb Ashamedb Enthusiasticb Afraidb Loss of appetite

a. Items removed in subscale development. b. Items from the Positive and Negative Affect Schedule (PANAS).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

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