Community Ment Health J (2011) 47:9098 DOI 10.

1007/s10597-009-9255-y

ORIGINAL PAPER

Carrying the Burdens of Poverty, Parenting, and Addiction: Depression Symptoms and Self-Silencing Among Ethnically Diverse Women
Therese M. Grant Dana C. Jack Annette L. Fitzpatrick Cara C. Ernst

Received: 24 November 2008 / Accepted: 2 October 2009 / Published online: 16 October 2009 Springer Science+Business Media, LLC 2009

Abstract Depression among women commonly cooccurs with substance abuse. We explore the association between womens depressive symptoms and self-silencing accounting for the effects of known childhood and adult risk indicators. Participants are 233 ethnically diverse, lowincome women who abused alcohol/drugs prenatally. Depressive symptomatology was assessed using the Addiction Severity Index. Multivariate logistic regression models examined the association between self-silencing and the dependent depression variable. The full model indicated a 3% increased risk for depressive distress for each point increase in self-silencing score (OR = 1.03; P = .001). Differences in depressive symptomatology by ethnic groups were accounted for by their differences in self-silencing. Keywords Depression Self-silencing Substance abuse Ethnicity

Introduction Alcohol and drug abuse among American women is a serious problem across all socioeconomic strata (Substance Abuse and Mental Health Services Administration [SAMHSA] 2002), and co-occurs with mental disorders at high rates. Substance abuse among pregnant women remains a particular concern, with approximately 1.9% of pregnant women reporting binge alcohol use (Centers for Disease Control [CDC] 2004) and 3.7% reporting drug use during the previous month on population-based surveys (SAMHSA 2002). Studies have reported a high incidence of cooccurring mental health disorders among substance abusing pregnant women, including overall psychological distress (Miles et al. 2001) and depressive symptoms (Burns et al. 1985; Marcenko and Spence 1995). The burden of depression coupled with substance abuse makes the treatment prognosis worse than for either problem alone (Bobo et al. 1998; Greeneld et al. 1998; Driessen et al. 2001). Therefore, it is critical to understand more about the interplay of risk factors for depression among women who abuse alcohol and drugs. Specic risk factors for womens depression have been identied in the literature; many of these also predict cooccurring substance abuse. Poverty is perhaps the strongest of these, especially in mothers with young children (Belle and Doucet 2003). Other risk factors include childhood physical and/or sexual abuse (Duncan et al. 1996; Wilsnack et al. 1997), and insecure and/or disrupted parentchild attachment (Cummings and Davies 1999). Adult risk factors for women include victimization and sexual violence (Koss et al. 2003), homelessness (Fisher and Breakey 1991), acute and chronic illness (Kiecolt-Glaser et al. 2002), and a critical, unsupportive partner (Hooley and Teasdale 1989).

T. M. Grant (&) C. C. Ernst Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 180 Nickerson St., Suite 309, Seattle, WA 98109-1631, USA e-mail: granttm@u.washington.edu D. C. Jack Fairhaven College of Interdisciplinary Studies, Western Washington University, Bellingham, WA 98225, USA T. M. Grant A. L. Fitzpatrick Department of Epidemiology, University of Washington, Box 354922, Seattle, WA 98115, USA

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Depression varies across ethnic groups in terms of prevalence rates (Saez-Santiago and Bernal 2003), symptom expression (Ayalon and Young 2003), and the meanings individuals attach to symptoms (Chung and Singer 1995; Hall et al. 1999). However, across all ethnic groups, female gender, poverty, low education levels, discrimination, and being single are associated with the occurrence of depressive symptoms (Blazer et al. 1994). One promising theory for investigating womens depressive symptoms is silencing the self (Jack 1991, 1999). Recognizing the signicance of close relationships for womens well-being, this model proposes that womens social inequality and social expectations regarding gender may give rise to specic cognitive schemas about the self in relationships that guide their thoughts and behaviors. These cognitive schemas can create a vulnerability to depression through directing a woman to defer to the needs of others, censor selfexpression, repress anger, judge the self against an ideal, and inhibit self-directed action, thus limiting both intimacy and autonomy. In combination with devaluing and restricting environments, silencing the self is thought to reinforce negative self-perception, lower self-esteem and result in feelings of a loss of self. Self-silencing has been found to be signicantly associated with depressive symptoms across diverse female populations who experience differing demands for self-silencing behaviors in their social contexts (Ali et al. 2002; Ali and Toner 2001; Duarte and Thompson 1999; Geller et al. 2000; Hart and Thompson 1996; Jack and Dill 1992; Kayser and Sormanti 2002; Page et al. 1996; Smolak and Munstertieger 2002; Thompson 1995; Thompson et al. 2001; Uebelacker et al. 2003; Woods 1999). In the original STSS study (Jack and Dill 1992), 92% of the women were White and thus the role of ethnicity in relation to depression and self-silencing was unexamined; later studies report inconsistent results regarding the association of self-silencing and depression among undergraduate women of diverse ethnicities (Gratch et al. 1995; Carr et al. 1996). The purpose of this study is to examine whether selfsilencing is associated with self-reported depressive symptoms among an ethnically diverse group of 233 lowincome women who abused alcohol and/or drugs during pregnancy. We hypothesized that we would nd a relationship between self-silencing and depressive symptoms, over and above the effects of known risk indicators. Given that co-morbidity of substance abuse and depression affects treatment outcomes for each condition, we also explored whether self-silencing is associated with severity of alcohol abuse and/or drug abuse, and whether the relationship between self-silencing and depressive distress varies by substance abuse severity.

Methods Overview The data presented in this study are from the ParentChild Assistance Program (PCAP), a 3-year public health advocacy/case management intervention for women who abuse alcohol and/or drugs during pregnancy (Ernst et al. 1999; Grant et al. 1996, 2003, 2005). The PCAP model is based on relational theory that posits the critical importance of afrming, supportive relationships within the intervention setting (Amaro and Hardy-Fanta 1995). Participants Women were eligible to participate if they: (1) were pregnant or up to 6 months postpartum; (2) self-reported heavy alcohol and/or illicit drug use during the index pregnancy; (3) were ineffectively or not at all engaged with community social services; and (4) lived in or near one of four cities served by PCAP in Washington State (Seattle, Tacoma, Yakima, or Spokane). Participants were referred by community providers who were familiar with the PCAP intervention through brochures, presentations, and word of mouth (e.g., social workers, public health nurses). PCAP clinical directors reviewed each referral for eligibility and contacted women who met inclusion requirements. A total of 282 participants enrolled in PCAP between December 1997 and June 2002 and completed a valid intake interview and the STSS within 3 months. Among these, 49 are excluded from analysis for the following reasons: missing data on one or more responses on the STSS (31); missing values on important control variables (9); under the inuence of alcohol or drugs at the time of interview (6); had a fetal alcohol spectrum disorder and were enrolled in a separate pilot study (3). Data from the remaining 233 participants are included in this analysis. Fifty-six percent of the women (n = 130) were enrolled prenatally. Procedure Intake interviewers were ve masters level mental health counselors and two licensed chemical dependency professionals, all of whom were White women with extensive experience working with ethnically diverse, substanceabusing women in their own communities. Interviewers used detailed instruction manuals and were trained to insure standardized interview procedures. PCAP case managers collected additional assessment data, including the STSS, at home visits within a 3-month window after enrollment. Every effort was made to make the assessment process less onerous for clients already burdened by the

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demands of social service agencies. Institutional Review Board approval was obtained from the University of Washington; a certicate of condentiality was obtained from the federal Department of Health and Human Services. Measures Addiction Severity Index Information about demographic factors, childhood risk indicators, and adult risk indicators was obtained during the intake interview using the Addiction Severity Index (ASI) 5th edition (McLellan et al. 1992). The ASI is a widelyused standardized instrument demonstrating good reliability and validity. The instrument assesses seven potential problem areas: Medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status. Standard scoring formulas have been developed to calculate ASI composite scores (McGahan et al. 1986) for each problem area; composite scores range from 0 to 1 with higher scores indicating greater severity. In 1997, PCAP researchers developed supplemental questions for pregnant and postpartum women regarding

childhood history, and alcohol and drug use during pregnancy. Demographics Demographic variables of interest are listed on Table 1. Participants self-identied ethnicity according to the categories White, Black, American Indian, Hispanic, and Asian. We combined Hispanic and Asian into a single Other designation because of the small number of cases. Childhood Risk Indicators (0 = No; 1 = Yes) These included sexual abuse, physical abuse, disrupted family attachment (including any of the following: Ever being raised outside biologic parent(s) care, involvement with child protective services, ever ran away as a child, mothers death prior to childs age 12). Adult Risk Indicators (0 = No; 1 = Yes) These included current transient housing (homeless, living in emergency shelter or temporarily with friends), ever

Table 1 Maternal demographic, childhood, and adult risk indicators by ethnic groups Characteristic All (N = 233) N (%) or M (SD) White (n = 123) n (%) or M (SD) Black (n = 28) n (%) or M (SD) Am Indian (n = 55) n (%) or M (SD) Other (n = 27) n (%) or M (SD)

Demographic characteristics Age (mean)a Parity (mean)b Education (mean) Never married Income (mean, past 30 days) Childhood risk indicators Disrupted family Sexual abusec Physical abuse Adult risk indicators Conicts (mean, past 30 days) Current transient housing Ever abused by sexual partnerd Chronic medical condition Jailed (mean # times) Prostitutione
a b c d

26.41 (6.37) 3.13 (1.89) 10.71 (1.99) 150 (64) $410 (286) 174 (75) 143 (61) 115 (50) .22 (.27) 72 (31) 196 (84) 109 (47) 7.56 (13.77) 59 (25)

26.11 (6.27) 2.79 (1.48) 10.88 (1.89) 74 (60) $384 (315) 94 (76) 89 (72) 60 (49) .19 (.26) 34 (28) 110 (89) 61 (50) 6.97 (15.17) 22 (18)

30.18 (6.35) 3.89 (2.44) 11.14 (1.78) 17 (61) $470 (224) 22 (79) 12 (43) 16 (57) .32 (.32) 10 (36) 26 (93) 14 (50) 12.21 (18.10) 12 (43)

25.55 (5.86) 3.53 (2.21) 10.33 (2.07) 38 (69) $449 (242) 37 (67) 29 (53) 27 (49) .23 (.26) 21 (38) 41 (75) 22 (40) 7.11 (8.89) 16 (29)

25.67 (6.79) 3.11 (1.91) 10.26 (2.31) 21 (78) $382 (281) 21 (78) 13 (48) 12 (46) .22 (.26) 7 (26) 19 (70) 12 (44) 6.33 (8.99) 9 (33)

Age: Black vs. White (P = .002), Black vs. American Indian (P = .001), Black vs. Other (P = .014) Parity: Black vs. White (P = .002), American Indian vs. White (P = .01) Sexual abuse: White vs. Black (P = .003), White vs. American Indian (P = .01), White vs. Other (P = .02)

Abuse by sexual partner: White vs. American Indian (P = .01), Black vs. American Indian (P = .05), White vs. Other (P = .03), Black vs. Other (P = .01) Prostitution: Black vs. White (P = .005)

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physically or sexually abused by a sexual partner, chronic medical condition (including conditions such as Hepatitis B or C, asthma, seizures, thyroid problems), and prostitution in the past 3 years. Other variables included number of times incarcerated (jail and/or prison), and conicts, calculated as the proportion of people the participant had conicts within past 30 days among those with whom she had contact. Alcohol Severity and Drug Severity (ASI Composite Scores, Range 01) ASI alcohol and drug severity scores are based on items asking about past 30-day experience of the following: (For alcohol) any use at all, alcohol to intoxication, number of days experiencing alcohol problems, how much money spent on alcohol; and ve-point ratings (0 = not at all to 4 = extremely) of how bothered the participant has been by these problems, and how important now is treatment for these problems; (for drugs) number of days used drugs (any of nine types), more than one substance per day, number of days experiencing drug use problems; and ve-point ratings (0 = not at all to 4 = extremely) of how bothered the participant has been by these problems, and how important now is treatment for these problems. Depressive Distress Score (DDS) PCAP intake instruments did not include a standardized depression measure; thus we created a measure of depressive distress, the Depressive Distress Score (DDS), comprised of four ASI psychiatric questions about past 30day experience of symptoms: Did the participant experience any of the following for at least 2 weeks of the past 30 days: (1) Serious depression (sadness, hopelessness, loss of interest, difculty functioning, crying jags); (2) trouble understanding, concentrating or remembering; (3) serious thoughts of suicide (even once had a plan); and (4) serious anxiety or tension (unreasonably worried, unable to relax, feeling uptight). The rst three symptoms are included in the DSM-IV under Major Depressive Disorder. We included the fourth symptom, serious anxiety or tension, because anxiety and depression are commonly encountered together; the category mixed anxietydepressive disorder is included in the Appendix of the DSM-IV (American Psychiatric Association [APA] 1994). A participants DDS (range 04) was calculated as follows: 0 = no symptoms reported; 1 = report of serious depression; 2 = report of serious depression plus any one other symptom; 3 = report of serious depression plus any two other symptoms; 4 = report of serious depression plus any three other symptoms.

Our a priori selection of the four DDS items was conrmed by principal component factor analysis (without rotation) of the seven ASI psychiatric symptoms. Three components were extracted. The four items comprising the DDS loaded on the rst component: Serious anxiety or tension (.74), serious depression (.68), suicidal thoughts (.67), and trouble understanding, concentrating or remembering (.63); this component explained 34.03% of the variance (Eigen value, 2.38). While our DDS measure does not include the full range of DSM-IV depressive symptoms, it does provide a measure of variability of depressive distress among the participants. Silencing the Self The Silencing the Self Scale (STSS) (Jack and Dill 1992) is a 31-item self-report instrument designed to measure the construct called self-silencing. Four theoretically derived subscales measure dimensions of self-silencing: Externalized Self-Perception (judging oneself by external, societal standards), Care as Self-Sacrice (considering others needs and feelings as more important than ones own), Silencing the Self (inhibiting self-expression), and the Divided Self (inner division resulting from presenting a false outer self). Respondents rate their agreement with items on a ve-point Likert scale. Higher STSS scores indicate a greater degree of self-silencing. The STSS was validated in three groups (undergraduate women, pregnant women, and a battered womens shelter group), demonstrating good construct validity, Cronbachs alpha ranging from .86 to .94, and testretest reliability of .86. In the present study, Cronbachs alpha for the 31-item scale was .90. Data Analysis Statistics were calculated using t-tests, analysis of variance (for continuous variables) or chi-square tests (for categorical variables). Post hoc pairwise comparisons were calculated by four ethnic groups for variables found to be statistically signicant. We used multivariate logistic regression to examine associations between STSS and the primary dependent variable DDS redened as a binary variable (0 = no depression symptom reported vs. 1 = any report of serious depression). We evaluated STSS in an unadjusted model, and in models that added additional covariates hierarchically as follows: Block 1: Demographics (with the four ethnic groups entered categorically); Block 2: Childhood risk indicators; Block 3: Adult risk indicators and alcohol and drug severity composite scores. Odds ratios (OR), 95% condence intervals (95% CI), and P-values were calculated.

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Two separate multiple linear regression models examined the association between STSS and the continuous dependent variables: (1) alcohol severity (ASI composite score); and (2) drug severity (ASI composite score) (Kleinbaum et al. 1988). In these models, the three blocks were entered together, DDS was included as a control variable, and STSS was entered on the nal step. All analyses were done using SPSS for Windows, version 11 (SPSS 2001).

American Indian women (53%, P = .01) and Other women (48%, P = .02). Black women (93%) and White women (89%) reported similar high rates of adult abuse by a partner, with both groups reporting higher rates than American Indian women (75%) (P = .05 and .01, respectively) and higher rates than Other women (70%) (P = .03 and .01, respectively). STSS Total and STSS Subscales Participants STSS Total scores were normally distributed, M = 86.0, SD = 20.9, range 37142 (Table 2). Pairwise comparisons found a signicant difference between Other women and White women on the STSS Total score (P B .05). Subscale ndings are reported on Table 2. We found signicant differences by ethnic group on all STSS subscales except Externalized Self Perception (ESP). Alcohol and Drug Severity Mean alcohol composite scores were lower (less severity) among White women compared to Black women and

Results Demographics and Childhood/Adult Risk Indicators Table 1 describes these characteristics by ethnic groups. Black women (M = 3.9, SD = 2.4) and American Indian women (M = 3.5, SD = 2.2) had more children than did White women (M = 2.8, SD = 1.5), P = .002 and .01, respectively. Black women had higher rates of prostitution (43%) compared to White women (18%, P = .005). White women reported higher rates of childhood sexual abuse (72%) compared to Black women (43%, P = .003),

Table 2 STSS total and subscale scores, ASI composite scores, depressive distress score and components by ethnic groups All (N = 233) N (%) or M (SD) STSS total score (mean)a STSS subscale scores (mean) Externalized self-perception Divided selfb Care-self sacricec Self-silencingd ASI composite scores (mean) Alcohol severitye Drug severity Depressive distress score (DDS) (mean)f Component symptoms, past 30-days (%) Serious depression Serious anxiety or tensiong Trouble concentrating, rememberingh Serious thoughts of suicide
a b c d e f

White (n = 123) n (%) or M (SD) 82.80 (20.87) 18.26 (5.47) 18.01 (6.34) 23.90 (6.31) 22.63 (7.83) .09 (.15) .13 (.09) .98 (1.38) 46 (37) 48 (39) 56 (46) 13 (11)

Black (n = 28) n (%) or M (SD) 90.82 (16.58) 18.32 (5.28) 22.86 (5.40) 25.04 (6.19) 24.61 (6.85) .15 (.19) .14 (.11) 1.57 (1.50) 16 (57) 15 (54) 12 (43) 3 (11)

Am Indian (n = 55) n (%) or M (SD) 87.15 (22.04) 18.31 (5.67) 19.62 (6.45) 24.25 (6.08) 24.96 (8.34) .20 (.22) .13 (.10) .53 (.94) 17 (31) 10 (18) 9 (16) 3 (6)

Other (n = 27) n (%) or M (SD) 93.37 (20.87) 19.70 (5.48) 18.67 (7.08) 27.67 (6.67) 27.33 (7.60) .12 (.24) .13 (.12) 1.11 (1.37) 13 (48) 11 (41) 8 (30) 3 (11)

86.02 (20.93) 18.45 (5.48) 19.05 (6.50) 24.56 (6.35) 23.97 (7.93) .12 (.19) .13 (.10) .96 (1.33) 92 (40) 84 (36) 85 (37) 22 (9)

STSS total score: Other vs. White (P B .05) Divided self: Black vs. White (P B . 001); Black vs. American Indian (P B .05); Black vs. Other (P B .05) Care-self sacrice: Other vs. White (P B .01); Other vs. American Indian (P B .05) Self-silencing: Other vs. White (P B .01) Alcohol severity score: American Indian vs. White (P B .001); Black vs. White (P B .05)

Depressive distress score: Black vs. American Indian (P B .001); White vs. American Indian (P B .05); Other vs. American Indian (P B .05); Black vs. White (P B .05) g Serious anxiety or tension: White vs. American Indian (P B .01); Black vs. American Indian (P B .01); Other vs. American Indian (P B .05)
h

Trouble concentrating, remembering: White vs. American Indian (P B .001); Black vs. American Indian (P B .05)

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95 Table 4 Multiple regression analyses examining associations between STSS and alcohol and drug severity (N = 233) Dependent variables Alcohol severity Blocks 1, 2, and 3 STSSa Drug severity Blocks 1, 2, and 3 STSSa
a

American Indian women. We found no signicant differences among ethnic groups on drug composite scores. Past 30-day illicit drug use reported by White, Black, American Indian, and Other women (respectively) was as follows: marijuana (13.8, 25.0, 14.5, 18.5%; P = .503), cocaine (8.9, 25.0, 29.1, 25.9%; P = .003), heroin (1.6, 0, 3.6, 7.4%; P = .268), and methamphetamines (10.6, 0, 3.6, 3.7%; P = .111) (data not shown on table). Past 30-day binge alcohol use (C5 drinks per occasion) was 6.5, 17.9, 20.0, 11.1%; P = .046. Depressive Distress Score Post hoc comparisons indicated signicantly lower DDS scores (less distress) among American Indian women compared to White women, Black women and Other women (Table 2). Among the four symptoms that comprise the DDS, the most frequently reported among participants was serious depression (39.5%), with no signicant differences by ethnic group. American Indian women reported less serious anxiety or tension than did White women, Black women and Other women; they also reported less trouble concentrating compared to White women and Black women (Table 2). The number of DDS symptoms reported by participants ranged from 0 to 4 (data not shown on table). Within each ethnic group, the highest proportion of women reported no symptoms: American Indian women (69%), White women (63%), Other women (52%) and Black women (43%). Among women with symptoms, the most commonly reported number was three for all groups except American Indian.

D R2

SE

.255 .003 .179 .007 -.0001 .0001 -1.37 .17 -.001 .001 -.93 .35

Controlling for Block 1 demographic, Block 2 childhood risk, and Block 3 adult risk covariates, and depressive distress score

Associations Between STSS and Depressive Distress Score The association between STSS and the binary dependent variable DDS was signicant in the unadjusted model and in the models adjusted for all covariates. In the full model (Block 3) there was a 3% increased risk for depressive distress for each one point increase in STSS score (OR = 1.03; 95% CI = 1.011.05; P = .001). Tests for interaction between STSS and ethnic groups were not statistically signicant (P = .70). When each STSS subscale was entered individually into the logistic model, every subscale signicantly predicted the risk of depressive distress (Externalized Self-Perception, P \ .006; Divided Self, P = .001, Care as Self-Sacrice, P = .04, Self-Silencing, P = .007 (data not shown on table). In examining alcohol severity and drug severity as dependent variables, we found no independent association with STSS (P = .35 and P = .17) controlling for demographic factors, childhood and adult risk indicators (Tables 3, 4).

Table 3 Multivariate logistic regression examining association between STSS and depressive distress (binary), controlling for demographic, childhood risk, and adult risk covariates (N = 233) Dependent variable Depressive distress Unadjusted Block 1: demographicsa Block 2: childhood risk Block 3: adult riskc
a b

Discussion This study examined whether self-silencing contributes to depressive distress above known risk indicators among low-income, ethnically diverse women who abused alcohol and/or drugs during pregnancy. Participants reported a high prevalence of factors known to predict adult depression and substance abuse. As children, most had undergone disrupted parental attachment, and had been either physically or sexually abused. As adults, these women experience dire relational and social circumstances in addition to their substance abuse. Our hypothesis that self-silencing would be signicantly associated with depressive distress was upheld. In the full model, we observed a statistically signicant 3% increased

OR

95% CI

1.02 1.02 1.02 1.03

1.0081.036 1.0071.04 1.0071.04 1.011.05

.002 .004 .005 .001

Block 1 demographic variables: age, parity, education, marital status, past 30-day income, ethnicity

Block 2 childhood risk variables: disrupted family attachment, sexual abuse, physical abuse Block 3 adult risk variables: conicts, current transient housing, ever physically or sexually abused by a sexual partner, chronic medical condition, number of times incarcerated, prostitution in past 3 years, alcohol severity score, drug severity score

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risk for depressive distress for each one point increase in STSS score. In other words, our ndings suggest that a participant in our study who had an STSS score 10 points higher than another participant would have a 30% increased risk for depressive distress. STSS independently predicted DDS over and above childhood risk indicators (including sexual abuse, a signicant covariate and known predictor of womens adult mental health disorders) and adult risk factors. Given the effects of social and economic disparities encountered by women of color (Amaro et al. 2005; Belle and Doucet 2003), as well as ethnic differences in gender role expectations and ideals of feminine goodness (Andersen and Collins 2003; Collins 2000; Comas-Diaz and Greene 1994) we anticipated nding differences among ethnic groups in self-silencing and on the depressive distress measure. While univariate analyses indicated signicant ethnic group differences both on depressive distress and on self-silencing, in the subsequent regression analysis ethnicity was not statistically signicant. Adjusting for all other variables in the model, the differences in depressive distress by ethnic group were accounted for by their differences in self-silencing. We speculate that the extreme social circumstances and vulnerable life stage of our study participants fostered the formation of self-silencing cognitions that were more powerfully associated with depressive distress than was ethnicity. We suggest that clinical treatment interventions consider helping women explore their self-silencing within different contexts, including the meanings and motivations of their self-silencing behaviors. Howell et al. (2005) examined depressive symptoms among 655 women between 2 and 6 weeks post-partum. Similar to results of our univariate analyses, they found that White women less frequently reported these symptoms (31.3%) than did African-American (43.9%, P \ .001). We note that American Indian participants in our study had a signicantly lower mean depressive distress score, and reported experiencing two of the four score symptoms at signicantly lower rates compared to other ethnic groups. Beals et al. (2005) likewise found that two large American Indian samples were at lower risk for major depressive episode compared with the National Comorbidity Survey sample. These ndings emphasize the importance of examining symptom meaning, display, and measurement of depression as it relates to ethnicity. Though our study did not inquire about onset of depressive symptoms, we examined data that could help indicate whether participants postpartum status was a signicant contributing factor in their self-report of depression. In comparing the 103 participants who were enrolled postpartum (44%) with the 130 enrolled during pregnancy (56%), we found virtually no differences in depression self-report (41 vs. 38%, respectively). Thus we

do not think report of depression was attributable to postpartum status. Other researchers suggest that postpartum depression is not a separate entity but rather a continuation of depression during pregnancy (Yonkers et al. 2001). The study had a number of limitations. PCAP is a community public health intervention that does not use a standardized depression measure. Stronger evidence for the association between STSS and depression would come from further investigation among women assessed for depression according to DSM-IV criteria using accepted procedures (see Ali et al. 2002). Our descriptive, crosssectional design does not allow us to infer a causal relationship between self-silencing and depressive symptoms. For almost half of the participants, the intake interview was a cross-racial interaction. The validity of self-report might be questioned due to mistrust of the interviewer, symptom exaggeration or minimization, and clients varying interpretation of interview questions based on cultural background. Findings should not be generalized beyond the population studied; the study should be replicated in a sample with greater numbers of women in each ethnic category. Our ndings add to a growing body of literature by demonstrating the signicant relationship between selfsilencing and womens depressive symptoms, even among women who carry the burdens of poverty, parenting, and addiction. We suggest that researchers prospectively investigate self-silencing as a possible cognitive-affective mediator between social context and depression.
Acknowledgments We extend special thanks to the ParentChild Assistance Program advocate/case managers and clinical supervisors, and to the women enrolled in the program for their valuable contributions to this work. This work was supported by contracts from the State of Washington Department of Social and Health Services (DSHS) #7141-1 and #7896-1.

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