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Postpartum depression (PPD) is characterized by a deep sense of hopelessness, helplessness, irritability, anger and physical depression following childbirth. This article reviews intrapersonal and external factors associated with the onset of PPD in women, how PPD can affect a woman's experience of motherhood, and the efficacy of up and coming treatment protocols for PPD.
Though the arrival of a new child is typically thought of as a time of joy and happiness, for many women this is not the case. Pregnancy and childbirth are major events in a woman's life-for many women the combination of interpersonal vulnerabilities along with external stressors can lead to the development of postpartum depression (PPD). PPD is characterized by a sense of helplessness, hopelessness, irritability, anger and physical depression following childbirth (Benoit et al., 2007). Research has shown that PPD affects between 10-15% of childbearing women and is thought to be as high as 20% for new mothers (Knudson-Martin & Silverstein, 2009; Vliegen & Luyten, 2009).
PPD has negative implications for the women experiencing it as well as for their families. Mothers suffering from PPD are less likely to breastfeed, typically engage in less play/talk with their newborns, and are less likely to comply with immunizations and well-child visits (Leis et al., 2009) than non-depressed mothers. Children of women with PPD are at risk for future emotional problems, difficulties with social interaction, and attachment insecurities (Leis et al., 2009).
Because of the prevalence of PPD and the potentially severe consequences of leaving PPD untreated, it is imperative that mothers receive early and effective treatment. Though PPD also occurs in men, this literature review will focus on PPD in women-looking specifically at intrapersonal and external factors associated with the onset of PPD, how PPD can affect a woman's experience of motherhood, and the efficacy of up and coming treatment protocols for PPD.
Predictors: Intrapersonal Factors
Personality dimensions, such as dependency and self-criticism, are thought to contribute to the onset of PPD because the post-partum period is a time when issues of relatedness and self-definition are likely to arise (Vliegen & Luyten, 2009). In 2009, Vliegen and Luyten examined dependency and self-criticism in depressed and non-depressed mothers. The researchers wanted to investigate whether these mothers differed in their respective levels of dependency and self-criticism as well as any potential relationship between these personality dimensions and the severity of symptoms.
Previous research has shown that individuals with high levels of dependency and self-criticism were significantly more likely to develop post-partum depressive symptoms (Vliegen & Luyten, 2009). Dependant individuals tend to be preoccupied with fears of abandonment and loss, while self-critical individuals tend to be preoccupied with self-definition, control and perfection (Vliegen & Luyten, 2009). These preoccupations come to the forefront after childbirth because this is a time when new mothers tend to reassess their interpersonal relationships as well as their feelings of identity and autonomy (Vliegen & Luyten, 2009). As such, the researchers hypothesized that women with PPD would have higher levels of both dependency and self-criticism and that these factors would be positively related to the severity of their depression (Vliegen & Luyten, 2009).
This study was comprised of 55 participants who met the DSM-IV criteria for major depressive disorder with post-partum onset, as well as 37 non-depressed mothers who had recently given birth. The Depressive Experiences Questionnaire was used to assess dependency and self-criticism, and the Beck Depression Inventory was used to assess the severity of depressive symptoms.
The results of this study supported the researcher's hypothesis. Their results indicated that the clinically depressed mothers had higher levels of self-criticism and increased levels of dependency compared to non-depressed mothers. Furthermore, in the post-partum depressed sample, both personality dimensions were found to be positively associated with the severity of depressive symptoms (Vliegen & Luyten, 2009).
Attachment Style is another factor that is thought to be associated with the onset of PPD. In 2008, Monk, Leight, and Fang looked at possible links between the dominant attachment styles of women and subsequent susceptibility to PPD. Previous research suggests that pregnant women with insecure attachment styles are at a greater risk for PPD (Monk, Leight & Fang, 2008). This is because the transition to parenthood is a life stressor that activates the attachment system. When a woman's dominant attachment style is insecure, she may experience pregnancy and the post-partum period as primarily negative and stressful because her insecure attachment has fostered a worldview in which interpersonal relationships are associated with dissatisfaction, low self-esteem and negative mood (Monk, Leight & Fang, 2008). As such, the researchers in this study hypothesized that women with an insecure attachment style will have a greater incidence of PPD than women with a secure attachment style.
Participants for this study consisted of 186 pregnant women who were assessed during their 2nd and 3rd trimester of pregnancy as well and again at 4 months post-partum. The Center for Epidemiological Studies Depression Scale was used to assess for current feelings of depression, the Pregnancy Experience Scale was used to assess their reactions to the experience of pregnancy, the Relationship Scales Questionnaire was used to assess close attachment relationships, and the Perceived Stress Scale was used to assess current life stress.
Results indicated that characteristics of attachment style assessed during pregnancy were strong predictors of PPD. Pregnant women who were more fearful and less secure with respect to relationships reported greater pregnancy distress and were at an increased risk of developing PPD (Monk, Leight & Fang, 2008).
Predictors: External Factors
External factors, such as income and availability to quality maternity care, are also thought to contribute to the onset of PPD. In 2007, Benoit, Westfall, Treloar, Phillips, and Jansson analyzed PPD in relation to social factors and quality of maternal care. Previous research has looked at stressful life conditions, such as economic hardships, and their link to PPD. Such research has shown thereto be a significant correlation between family income, specifically financial worries, and depression among new mothers (Benoit et al., 2007). Similar studies have looked at maternity care and found a link between low satisfaction of the birthing experience and PPD (Benoit et al., 2007).
This study was comprised of 106 women who had recently given birth. The Beck Depression Inventory was used to assess for the occurrence and severity of depressive symptoms, and a self-report questionnaire was used to assess for birth experience satisfaction. The self-report questionnaire was followed by an interview asking participants a series of open-ended questions designed to elicit an explanation of their responses.
Results indicated support for the researcher's hypothesis. There was a significant association between PPD and household income-low income mothers had an increased incidence of PPD. There was also a significant association between the mother's satisfaction with her birthing experience and PPD-low satisfaction correlated with a higher incidence of PPD (Benoit et al., 2007).
Another external factor believed to contribute to the onset of PPD is the experience of birth trauma. In 2006, White, Matthey, Boyd and Barnett looked at the co-occurrence of post-traumatic stress (PTSD) symptoms, resulting from traumatic birth experiences, and PPD. Though the research in this area is relatively new there have been several studies linking symptoms of birth-related PTSD and PPD. A handful of studies have found that women who met full DSM-IV criteria for PTSD in the post-partum period also indicated a co-morbid occurrence of major depression (White et al., 2006). In keeping with these findings, the researchers in this study hypothesized that women experiencing symptoms of PTSD in the post-partum period would also meet qualifications for major depression in the post-partum period.
Participants for this study consisted of 400 women who had recently given birth. The Post-traumatic Stress Symptom Scale was used to assess symptoms of PTSD and the Edinburgh Postnatal Depression Scale was used to assess symptoms of depression. Items on the Post-traumatic Stress Symptom Scale that referred to 'trauma' were altered to refer to 'the labor or birth' in order to assess trauma specifically related to the birthing experience (White et al., 2006).
Results from this study supported the researcher's hypothesis. The prevalence of women who met full criteria for PTSD was 2% of the sample, however many more women indicated significant experiences of trauma but did not meet full diagnostic criteria for PTSD. Of these women, 42% indicated symptoms consistent with major depression-indicating a high degree of co-morbidity between depression and PTSD (White et al., 2006).
Effect on Motherhood
PPD can greatly impact a woman's experience of motherhood. Motherhood is generally thought of as something that comes naturally to women and a time of incredible happiness and joy in their lives. Women internalize this social construction of motherhood and when reality does not live up to their expectations they often experience feelings of guilt, shame, withdrawal and isolation.
A review of qualitative studies on PPD was done by Knudson-Martin and Silverstein in 2009, looking at how the social construction of motherhood affects a woman's experience of motherhood. The authors reviewed the relational context within which PPD occurs and found that:
"PPD is experienced as a cumulative struggle in which expressing negative feelings is not congruent with social constructions of motherhood. As a result of these silencing processes, women become overwhelmed with feelings of incompetence and connection with others is difficult to maintain. This leads to isolation and detachment from their children, significant others and even themselves." (Knudson-Martin & Silverstein, 2009)
The authors found that women were deeply ashamed by their feelings of inadequacy because their reality was so far off from their notions of what motherhood should be like. These women struggled with their internalized ideal of the 'perfect mother' and blamed themselves for their inadequacies instead of questioning the ideal itself (Knudson-Martin & Silverstein, 2009). And furthermore, because these women anticipated a lack of understanding from others they almost always internalized their feelings instead of expressing them-leading to feelings of isolation which only served to maintain their depression (Knudson-Martin & Silverstein, 2009).
A similar review was done by Lee in 1997, looking to explore how women experience the transition to motherhood within the context of PPD and cultural expectations. The author reviewed the clinical literature and found that becoming a new mother is a major life event which poses extensive adjustment problems for most women (Lee, 1997). Furthermore, the author notes that cultural expectations describing motherhood as easy and stress free foster high levels of guilt and feelings of inadequacy in women who do not meet these expectations (Lee, 1997).
The review goes to on describe how the media perpetuates the cultural view that women should experience only happiness and love upon the arrival of their new baby-rarely acknowledging the physical and emotional challenges. When women find their experiences to be very different from their expectations they again experience strong feelings of guilt and failure (Lee, 1997).
PPD can also result in mothers experiencing an impaired ability to interact with their infants. In 2008, Goodman, Broth, Hall and Stowe examined at the quality of mother-infant interactions among mother who were experience significant symptoms of PPD. Previous research has looked at the quality of mother-infant interaction in depressed mothers and the subsequent functioning of the infants as they developed. Such research has shown that higher levels of depression in mothers are correlated with higher impairments in mother-infant interactions. These studies also indicated that infants with depressed mothers were less happy, indicated higher levels of tension, were more distressed, scored lower on the Bayley Scales of Infant Development, and had higher rates of insecure attachment than infants of non-depressed mothers (Goodman et al., 2008).
This study was comprised of 44 mothers. The Structured Clinical Interview for DSM-IV and the Beck Depression Inventory to assess for symptoms of PPD, the Parenting Sense of Competence Scale was used to determine maternal parenting efficacy beliefs, and the Parent-Child Early Relational Assessment Scales were used to measure mother-infant interaction quality.
Results indicated that depressed mothers indicated lower levels of perceived parenting efficacy as well as lower levels of positive mother-infant interactions. After 12 weeks of treatment the mothers had a significant reduction in depressive symptoms along with higher levels of perceived parenting efficacy and higher levels of positive mother-infant interactions (Goodman et al., 2008).
Cognitive behavioral therapy (CBT) has been consistently shown to be an effective treatment for major depression (Ammerman et al., 2005) and the same has held true for the treatment of women with PPD. CBT for depression and PPD focuses on problematic cognitions and subsequent problematic behaviors. CBT emphasizes the 'here and now' and takes a practical, problem-solving approach to dealing with PPD-related issues (Cooper et al., 2003). A comprehensive review of 48 clinical trials on depression treatment and relapse prevention showed CBT to be more effective than medication and other therapies (Ammerman et al., 2005).
In 2005, Ammerman and his colleagues assessed the efficacy of and adapted CBT program for first time mothers with PPD. In keeping with previous findings, the researchers hypothesized that the adapted CBT program would decrease symptoms of depression by altering maladaptive cognitions and activating more productive behaviors.
The participants for this study consisted of 26 first-time mothers. The Primary Care Evaluation of Mental Disorders was used to screen for common psychiatric disorders, the Beck Depression Inventory was used to screen for depression in particular and the Maternal Attitudes Questionnaire was used to identify cognitions and attitudes relating to motherhood.
Findings from this study supported the researcher's hypothesis. Mothers participating in the adapted CBT program showed a substantial reduction in their symptoms of depression and an increased ability to cope with stress (Ammerman et al., 2005). Mothers in the treatment group also showed improved attitudes toward motherhood and reported feeling more confident, effective, and closer to their children (Ammerman et al., 2005).
Though CBT is effective when used individually, CBT has recently been found to be particularly effective when utilized in a group format for women with PPD. In 2007, Griffiths and Barker-Collo examined the effectiveness of a structured psycho-educational and cognitive behavioral therapy group for women with PPD. Previous research has shown a positive correlation between the use of CBT as a treatment protocol and women with PPD. One study found that women participating in a 10-week CBT group had reduced depression scores on the Edinburgh Postnatal Depression Scale at the end of treatment (Griffiths & Barker-Collo, 2007). A similar study found that women attending a CBT based psycho-educational group indicated a reduction in PPD and anxiety symptoms upon completion of the program (Griffiths & Barker-Collo, 2007). In keeping with these findings, Griffiths and Barker-Collo hypothesized that their CBT-based group treatment approach would decrease levels of depression and anxiety in women with PPD.
Participants for this study consisted of 45 women with infants under the age of 1. The Edinburgh Postnatal Depression Scale was used to assess for symptoms of depression, the Beck Anxiety Inventory was used to assess for anxiety symptoms, and the Maternal Attitudes Questionnaire was used to identify cognitions and expectations relating to motherhood.
Results supported the researcher's hypothesis. Women in the CBT-based group had reduced symptoms of anxiety and depression as well as improved attitudes toward mothering (Griffiths & Barker-Collo, 2007). The group format seemed to be particularly effective in this study-more than half the sample said that meeting other women with similar issues was the most helpful part of the group (Griffiths & Barker-Collo, 2007).
Women participating in CBT groups can also benefit from mother-infant interactions within the group setting. In 2008, Clark, Tluczek and Brown looked at the efficacy of a mother-infant therapy group model for the treatment of PPD. Though many PPD related studies have assessed the implications for infants participating in mother-infant based therapy, few have looked at the implications for the mother. The few studies that did focus on the mother found that treatments including a mother-infant component reduced PPD symptoms to a greater extent than those that did not include a mother-infant component (Clark, Tluczek & Brown, 2008). As such, Clark, Tluczek and Brown hypothesized that the mother-infant therapy group model would be an effective mode of treatment for mothers with PPD.
This study was comprised of 32 women and their infants. The Beck Depression Inventory was used to assess for symptoms of PPD and the Parenting Stress Index was used to assess the level of stress indicated in the parent-child relationship. The Bayley Scales of Infant Development were used to assess the child's functioning and the Parent Child Early Relational Assessment was used to assess the quality of mother-child interactions.
Results from this study supported the researcher's hypothesis. The researchers found that a mother-infant group therapy model was significantly more effective in reducing mothers' depressive symptoms than standard care (Clark, Tluczek & Brown, 2008). Results also indicated that mothers showed more positive involvement and communication with their infants as well as improved perceptions of their infants (Clark, Tluczek & Brown, 2008).
Another treatment protocol that has been garnering attention in PPD research is the home-based intervention. Because the very nature of depression typically involves lowered energy and motivation, the ability for women with PPD to attend traditional therapy sessions can be compromised. This problem is compounded for low-income mothers who may be facing additional stressors such as lack of transportation or lack of funds for childcare (Beeber et al., 2004). Because low-income mothers are already at a high-risk for developing PPD, finding an accessible therapeutic solution for them is very important. Home-based interventions can be an effective solution for the women with PPD who are not ideal candidates for traditional therapeutic modalities.
In 2004, Beeber, Holditch-Davis, Belyea and Funk examined the feasibility and effectiveness of a home-based intervention for low-income mothers with PPD. Previous research has shown home-based interventions to be useful for low-income families, but few have looked specifically at low-income mothers with depression (Beeber et al., 2004). Due to the success with home-based interventions in past studies, the researchers for this study hypothesized that home-based services would also be effective in treating mothers with PPD.
Participants for this study consisted of 16 mothers whose income fell below the federal poverty level. The Center for Epidemiological Studies-Depression Scale was used to screen for depression and maternal-child observation was used to measure maternal interactions. The intervention included symptom management strategies, addressing problematic life issues, improving social support, and how to be an effective parent while symptomatic (Beeber et al., 2004).
The researcher's results supported their hypothesis. Their results indicated that the women participating in the home-based intervention showed a significant reduction in depressive symptoms (Beeber et al., 2004). The women also reported greater self-efficacy, improved parenting interactions and rapid relief from their symptoms (Beeber et al., 2004).
Home-based interventions that utilize at CBT-based approach have been found to be particularly effective in treating at-risk women with PPD. In 2002, Chabrol and his colleagues evaluated the effectiveness of a CBT-based approach for at-risk women in a traditional clinical setting versus a home-based setting. Previous research has shown home-based interventions to be effective for at-risk women with PPD, however very few have looked at the differences in treating at-risk women specifically with CBT in a home setting.
This study was comprised of 48 women with PPD. The Edinburgh Post-natal Depression Scale was used to screen the women for PPD initially, and both the Hamilton Depression Rating Scale and the Beck Depression Inventory were used to assess symptom severity over the course of the study.
Results from this study indicated significant differences between the outcomes of the women randomly assigned to a home-based program and the women randomly assigned to a clinic-based program (Chabrol et al., 2002). The women in the home-based CBT program had significant reductions in their symptom severity as well as significantly higher recovery rates than the clinic-based CBT group (Chabrol et al., 2002).
Home-based interventions which include mother-infant interactions have also been effective in treating at-risk women with PPD. In 1996, Gelfand, Teti, Seiner and Jameson examined the efficacy of an in-home, mother-infant intervention program for at-risk mothers with PPD. As mentioned before, previous research has shown home-based interventions to be effective for at-risk women with PPD, however very few have looked at the differences in treating at-risk women specifically with a mother-infant approach in a home setting. Gelfand and her colleagues hypothesized that the women in the mother-infant treatment group would show improvements in their mood, outlook and behavior (Gelfand et al., 1996).
Participants consisted of 111 mothers who had recently given birth. The Beck Depression Inventory was used to assess symptom severity in the depressed mothers, the Hassles Scale was used to assess everyday stressors, the Parenting Stress Index was used to assess parenting related stressors, and the Maternal Self-Efficacy Scale was used to assess the mothers' self-efficacy.
Results from this study supported the researcher's hypothesis. Results indicated that the mothers in the mother-infant treatment group successfully improved their scores on the Beck Depression Inventory (Gelfand et al., 1996). These mothers also reported a reduction in stress levels and less difficulties responding to fussy children (Gelfand et al., 1996).
Infant massage is another up and coming treatment protocol that has been shown to be effective in reducing depressive symptoms in women with PPD. Research has indicated that adults performing infant massage have shown a reduction in stress-levels, depressive symptoms and feelings of anxiety (Feijo et al., 2006). Many studies have documented the benefits for infants who received skin-to-skin contact such as massage, but only recently have researchers begun looking at the benefits for the adults performing the massage (O'Higgins, Roberts & Glover, 2008). In 2006, Feijo and her colleagues assessed the benefits of infant massage specifically in mothers with PPD-hypothesizing that the women would decrease their levels of depression and anxiety by performing infant massage on their preterm infants.
The study was comprised of 40 mothers and their preterm infants. The State Anxiety Inventory was used to determine pre and post test anxiety levels, the Profile of Mood States-Depression Subscale was used to determine pre and post test depression levels and the Infant Massage Questionnaire was used to determine personal reactions to the infant massage. The women watched a demonstration on infant massage and then the treatment group repeated the procedure on their own infant (Feijo et al., 2006).
The results supported the researcher's hypothesis. The group that preformed the massage, as well as the group that only observed the massage, reported a decrease in symptoms of depression (Feijo et al., 2006). However, the women who actually preformed the massage also experienced a decrease in symptoms of anxiety (Feijo et. al, 2006). Because PPD often has co-occurring anxiety it seems that to get the most benefit from infant massage its best to have the mothers perform the massage themselves.
Infant massage is also effective in facilitating positive mother-child interaction. Because mothers with PPD are known to have impaired interactions with their infants (Onozawa et al., 2001) it follows that infant massage would help depressed mothers better interact with their infants. In 2001, Onozawa, Glover, Adams, Modi and Kumar examined the efficacy of infant massage on mother-infant interaction in women with PPD. The researchers hypothesized that the mothers participating in the infant massage would decrease their depressive symptoms, better understand their infant's behavioral clues and subsequently have increased positive interactions with their infants (Onozawa et al., 2001).
The participants for this study were comprised of 59 women with depression who had recently given birth. The Edinburgh Post-natal Depression Scale was used to assess for depressive symptom severity and a videotaped play session between mother and infant was analyzed to assess mother-infant interactions. The play session consisted of face-to-face play between mother and infant and was rated on the basis of the maternal interaction (warmth, intrusiveness), the infant interaction (attentiveness, liveliness, and happiness/distress), and the interaction itself (smooth/difficult, fun/serious, mutual satisfaction, and engagement) (Onozawa et al., 2001).
Results from this study supported the researcher's hypothesis. The depression scores for women in the massage group showed more improvement than those in the control group (Onozawa et al., 2001) and all aspects of the mother-infant interaction assessment showed marked improvement for the massage group as well (Onozawa et al., 2001).
This literature review has taken an in-depth look at the factors that contribute to the onset of PPD, the effect of PPD on a mother's transition to motherhood, and effective treatment strategies. Paper two will detail a comprehensive group treatment strategy for women with PPD based on the research found in this review. The psychoeducational/skill-building group will have elements of CBT as well as a mother-infant component focusing on infant massage. Logistical concerns dictate that in-home treatment will not be a part of the proposed group, however the research provided here would make a sound foundation for an in-home treatment protocol should it be formulated in the future.