Postpartum Depression

There has been considerable clinical and research interest in postpartum depression. This has been largely provoked by the accumulating evidence that postpartum depression is associated with disturbances in child socioemotional development. This evidence has renewed concern about the epidemiology of postnatal depression, its etiology, methods of prediction and detection, and the most appropriate form of management.

The Nature of Postpartum Depression

Postpartum depression must be distinguished from two other mood disorders which occur after the birth of a child. The first is the maternity blues, a common disturbance in mood, which arises in the first few days following delivery and usually remits within a week or two, and is characterised by marked swings in mood (lability). It is not, in itself, of psychiatric significance. The second category of disorder is the postpartum psychoses which arise in the early weeks following delivery. These disorders affect around one in one thousand postpartum women. They cover a wide spectrum of psychiatric conditions, the most common being manic in form. They are of major psychiatric significance and frequently require hospital admission. In terms of severity, postpartum depression lies between these two classes of disturbance. The clinical profile is the same as depressions arising at other times (Cooper et al. 1988; O'Hara 1997). Thus, central to the depression is a protracted period of low mood accompanied, in varying combinations and to varying degrees, by a loss of interest and pleasure, sleep and appetite disturbance, concentration problems, irritability, feelings of guilt and worthlessness, anxiety symptoms, and, on occasion, suicidal thoughts.

Epidemiology and Course

Epidemiological studies of postpartum samples have consistently revealed that approximately 10 percent of women experience a non-psychotic major depressive disorder in the early weeks following delivery (O'Hara 1997). Although this does not represent an increase over the non-postpartum rate (Cooper et al. 1988; O'Hara et al. 1990), the inception rate for depression in the first three months postpartum does appear to be elevated compared to the succeeding nine months. The duration of postpartum depression is similar to that of depressions arising at other times; in other words, episodes typically remit spontaneously within two to six months. Some residual depressive symptoms are, however, not uncommon, and can persist up to a year following delivery (O'Hara et al. 1990; Cooper et al. 1988). Some cultural variation in the rate of postpartum depression is apparent. Thus, although a rate similar to that found in Western groups has been reported for a Chinese sample (Lee et al. 2001) and for a Nigerian sample (Aderbrigbe, Gureje, and Omigbodun 1993), a substantially lower rate has been found in a Malaysian sample (Grace et al. 2001), and in an indigent urban South African postpartum sample the rate was found to be as high as 34 percent (Cooper et al. 1999). The high prevalence in the latter sample probably reflects a response to the endemic levels of extreme socioeconomic adversity.

Etiology

There is little evidence to support a biological cause for postpartum depression (O'Hara 1997). Despite extensive research on steroid hormones in women after birth, no firm evidence has emerged linking these hormones to the development of postpartum depression

Several studies have found that the presence of maternity blues in the immediate postpartum period is related to the subsequent development of postpartum depression, but no hormonal basis to this association has been identified (O'Hara 1997). Obstetric factors are important in a vulnerable subgroup of women: amongst those with a previous history of depressive disorder, delivery complications are associated with a raised rate of postpartum depression (Murray and Cartwright 1993; O'Hara 1997).

Epidemiological studies have consistently shown that the major factors of etiological importance are largely psychosocial (O'Hara 1997). Thus, the occurrence of stressful life events, including unemployment, a dysfunctional marital relationship, and the absence of support from family and friends, has been found to raise the risk of postpartum depression. A psychiatric history is also commonly reported to be a risk factor for postnatal depression, especially a history of depressive disorder. The importance of this latter association was clarified in a five-year follow-up study of two subgroups of primiparous women who had had a postpartum depression: those for whom the postpartum depression was a recurrence of previous non-postpartum mood disorder, and those for whom the postpartum depression was their first experience of affective disturbance (Cooper and Murray 1995). The former group was found to be at raised risk for subsequent non-postpartum depression, but not to be at risk for depression following a subsequent delivery. Conversely, the latter group was found to be at raised risk for subsequent postpartum depression but not for subsequent non-postpartum depression. This suggests that for a subgroup of those with postpartum depression the birth of a child carries specific biological or psychological risks.

Prediction

Although a number of studies have reported on antenatal factors associated with postpartum depression, the samples used have usually been too small to derive a reliable predictive index. By the end of the twentieth century the only large-scale predictive study conducted revealed that the most reliable predictors of postpartum depression—such factors as the absence of social support or a previous history of depression—each approximately doubled the odds over the base rate risk (Cooper et al. 1996). The predictive index derived from this study is somewhat useful: at a cutoff score of twenty-six about a third of those who will develop postpartum depression are identified, and about a third of those scoring above this cutoff become depressed. It is unlikely, given the modest elevation of odds conferred by all antenatal risk factors identified to date, that an antenatal predictive index could be produced with substantially better predictive power.

The prediction of postpartum depression could probably be improved if account were taken of certain postpartum factors. For example, a study that examined the impact of early postpartum factors on the course of maternal mood (Murray et al. 1996b) found that, beyond the predictive contribution of antenatal factors, both a high maternity blues score and certain neonatal factors (infant irritability and poor motor control) were significantly related to the onset of postnatal depression. Because both the maternity blues and the neonatal infant factors contribute predictively over and above antenatal variables, the predictive value of critical antenatal factors could be improved by taking account of these postpartum variables.

Detection

Although postpartum depression is frequently missed by the primary care team (Seeley, Murray, and Cooper 1996), its detection does not present any special clinical problem. As noted above, the disorder's symptoms are not distinctive and its assessment is straightforward. Indeed, a simple self-report measure, the Edinburgh Postnatal Depression Scale (EPDS), has been developed as a screening device (Cox, Holden, and Sagovsky 1987). The questionnaire has sound psychometric properties (Murray and Carothers 1990), is easy to administer and simple to interpret, and could readily be incorporated within the routine services provided to all postpartum women. Sensitive clinical inquiry with those who have high EPDS scores would be sufficient to confirm the presence of a depressive disorder.

Impact on Family Life, Parenting, and Child Outcome

Little research has been conducted on the impact of postpartum depression on family life. However, in a study of a non-postpartum group of depressed patients, the impact on partners was found to be considerable and far-reaching, including restrictions in social and leisure activities (going out less frequently, seeing people less often), a fall in family income, and a considerable strain on the marital relationship (Fadden, Bebbington, and Kuipers 1987). A questionnaire study of a small sample found the same adverse impact in the case of postpartum depression (Boath, Pryce, and Cox 1998). Interestingly, the partners of women with postpartum depression have been found to have a significantly elevated rate of depression themselves (Ballard et al. 1994).

There have been a number studies on the impact of postpartum depression on the early mother-infant relationship. These have consistently shown difficulties in the interactions between depressed mothers and their infants, most notably either withdrawn and disengaged behavior in the mother, or intrusive and hostile mother-infant communication (Field et al. 1990). These difficulties are most apparent in groups with high adversity levels, but even in low risk samples depressed mothers have been found to respond less sensitively to their infants than well mothers (Murray et al. 1993; Murray et al. 1996a), particularly when the mood disturbance persists (Campbell, Cohn, and Meyers 1995). Follow-up studies also indicate an association between the maternal mood disorder and aspects of child development. Thus, one study conducted in Cambridge, U.K., found an adverse effect on child cognitive performance among eighteen-month-old infants of mothers who had had a postpartum depression (Murray 1992; Murray et al. 1996b). Although cognitive disturbance was not found to persist in this study, two London studies found cognitive deficit persisting in boys of mothers with postpartum depression when the children were aged four to five (Cogill et al. 1986; Sharp et al. 1995). Poor emotional adjustment in children has reliably been shown to be associated with postpartum depression. Thus, the majority of studies which have systematically examined infant attachment in the context of postpartum depression have found an elevated rate of insecure attachments (Martins and Gaffan 2001). There is evidence that these emotional problems persist into later childhood. A follow-up study of the Cambridge cohort found that the five-year-old children of mothers who had had postpartum depression were significantly more likely than controls to be rated—by both their teachers and their mothers—as behaviorally disturbed (Sinclair and Murray 1998; Murray et al. 1999). One major conclusion from these studies is that the mechanism mediating the association between postpartum depression and adverse child developmental outcome is the impaired pattern of communication between the mother and her infant.

Treatment

There has been little systematic research on pharmacological treatment of postnatal depression. Although progesterone treatment has been enthusiastically advocated (Lawrie, Herxheimer, and Dalton 2000), there has been no systematic evaluation of its clinical utility. By the end of the twentieth century, there has been only one controlled trial of an antidepressant medication, and it showed significant antidepressant effect for both the active drug and the comparison psychological treatment (Appleby et al. 1997). However, there was no additive effect of the two treatments, and the drug treatment was not found to be superior to the psychological treatment. It should be noted that less than half of those invited to take part in the study agreed, mainly because of reluctance to take the medication. This suggests that this line of treatment is not appropriate as a first line treatment, especially in view of the positive results obtained using other forms of intervention which are highly acceptable to women, and that pharmacological treatment should be reserved for those with particularly severe depression or those whose mood disturbance fails to respond to other measures.

There have been a number of controlled trials of psychological treatment of postpartum depression. In an early study, whose findings were later replicated, Holden and her colleagues (Holden, Sagovsky, and Cox 1989) found that improvement in maternal mood in women visited an average of nine times in thirteen weeks by Health Visitors trained in non-directive counselling was substantially greater than in the control group who received routine primary care. Similar positive benefits to maternal mood have been reported for other forms of psychological intervention, such as cognitive behavior therapy, psychodynamic therapy (Cooper and Murray 1997; Cooper and Murray 2001), and interpersonal psychotherapy (O'Hara et al. 2000).

Few studies have examined the impact of treating postpartum depression on the quality of the mother-infant relationship and child development. One controlled psychological treatment trial found that intervention was associated with significant improvement in maternal reports of infant problems, both immediately after treatment (4 to 5 months postpartum) and at a follow-up at eighteen months postpartum; these benefits were confirmed by independent teacher reports of behavior problems at age five (Cooper and Murray 1997; Murray and Cooper 2001). Moreover, early remission from depression, itself significantly associated with treatment, was related to a reduced rate of insecure infant attachment at eighteen months. Similar benefits have been reported in a study of Health Visitor practice (Seeley, Murray, and Cooper 1996). Training was provided to all the Health Visitors working in one National Health Service sector and a cohort study was conducted to assess Health Visitors' clientele before their training and then during a post-training period. Again, significant benefits were apparent in terms of both maternal mood and maternal reports of the quality of the mother-infant relationship.

Marital therapy has been proposed as a treatment for postpartum depression (Apfel and Handel 1999) and as "the treatment of choice" in cases where the marital relationship is in crisis because of the partner's inability to respond empathically to their spouse's distress (Whiffen and Johnson 1998). However, there is no reliable evidence to support such a proposal. Indeed, such an approach is likely to be appropriate only in a selected subgroup of those with postpartum depression where the spouse is available and willing to engage in a therapeutic process of this sort.

Conclusion

Postpartum depression has a significant adverse impact, not just on the affected woman, but on her partner and the family as a whole. This is of special importance to the infant who is so dependent on the mother for its care. It is of great concern that follow-up studies of the children of mothers who have experienced postpartum depression reveal an enduring adverse impact on the child's socioemotional development. It appears that these adverse child outcomes are driven by disturbances in the mother-child relationship which begin in the early postpartum period. This highlights the importance of early detection and treatment by the primary care health team. It also suggests that efforts should be directed to the identification of high risk samples and to the development and evaluation of preventive interventions.

See also:Attachment: Parent-Child Relationships; Depression: Adults; Loneliness

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peter j. cooper lynne murray