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Summary of Current Literature
October 2000
For practitioners, educators, policy makers, researchers, men, women, and children alike, maternal depression is an important social and health issue. Maternal depression is a complex and multifaceted illness that affects a woman's well-being, her overall functioning, her ability to work, and her relationships, including those with her spouse, partner, children, co-workers, and friends.
An Introduction to Depression
It is not unusual for life to be full of emotional highs and lows. However, when the low periods are long lasting or impair one's ability to function, that individual may be suffering from a serious common illness called depression. Major depression affects roughly 10 to 25 percent of adults in the U.S. each year. Depression is one of the most common and disabling psychiatric disorders, affecting individuals from all walks of life regardless of education, economic status, or ethnicity (Williams & Stasser, 1999).
However, prevalence varies among different groups of people. For example, depression occurs more frequently in females, young adults, and individuals with less than a college education (Blazer, Kessler, McGonagle, & Swartz, 1994). Women experience depression at 1.5 to 3 times the rate of men (Kessler, 2000; Kessler, McGonagle, Zhao, et al., 1994). The peak age of occurrence is 18 to 29 years, with high rate of prevalence continuing through 44 years (Epperson, 1999; Wittchen, Knauper, & Kessler, 1994). This age of occurrence overlaps with the prime childbearing years.
Manifestations of Maternal Depression: Focus on Prenatal and Postpartum Depression
Pregnancy and new motherhood may be times of increased risk for depression, due to hormonal and biological changes, as well as to the stress and demands pregnancy and new motherhood inflict. In addition to the common physical and mental manifestations of depression, women depressed during pregnancy show different brain activity patterns along with high levels of stress hormones (Lundy et al., 1999). Postpartum depression is a clinical term used to indicate a depressive episode experienced by a mother that is linked with childbirth. It can range in intensity and degree from mild and transient "baby blues" following childbirth, to severe, incapacitating psychotic depression. Fearful thoughts of harm coming to the baby and guilty feelings about being a bad mother are common in postpartum depression.
Twenty-six to 85% of women experience the "baby blues." This wide range in prevalence estimates is due to the fact that cases of baby blues often go undocumented. The blues are characterized by relatively mild and transient depressive symptoms such as prolonged and unexplainable tearfulness, poor sleep, as well as a sense of vulnerability, anxiety, and mood instability. These symptoms typically crest four to five days after childbirth and disappear a few days later (Epperson, 1999).
Postpartum major depression occurs in approximately 10% of childbearing women and often goes largely unrecognized, and thus untreated (Epperson, 1999; Stuart, 2000a; Williams & Stasser, 1999). Left untreated, it may persist for several months or even into the second year postpartum, with the possibility of relapse. The symptoms of postpartum major depression, including despondency, tearfulness, feelings of inadequacy, guilt, excessive anxiety, irritability, and fatigue (Epperson, 1999) extend beyond the normal duration of "baby blues" and are more debilitating. On the severe end of the continuum, about 1 to 2 in 2,000 women have postpartum mood episodes with psychotic features including hallucinations or delusions (American Psychiatric Association, 1994).
"Tell-tale" Signs and Assessment of Postpartum Depression
The detection of postpartum depression can be difficult because similarities exist between the normal course of childbirth and symptoms of depression. For example, weight and energy loss, diminished concentration, and sleep disturbance are all typically related to childbirth. Although seemingly "normal," these symptoms may indicate major depression. Following delivery some women have difficulty bonding or are disinterested in their babies, and feel guilty about their depressed feelings during a period they believe should be happy. While some women may not recognize these feelings as unusual, others are afraid to admit these feelings out of shame and/or guilt (Epperson, 1999).
There are some common "tell-tale" signs of depression (Kruckman & Smith, 1998; Stuart, 2000a):
- Depressed, sad or "empty" mood;
- Lack of interest in activities;
- Lack of appetite or pleasure in eating;
- Sleep disruptions;
- Excessive tiredness/decreased energy;
- Lack of motivation;
- Feelings of guilt;
- Feeling of worthlessness;
- Excessive irritability;
- Inability to cope;
- Poor concentration;
- Persistent anxiety;
- Thoughts or attempts of suicide; and
- Pre-occupation with death.
Certain traits and experiences put a mother at greater risk for depression including experiencing a significant negative life event, suffering "baby blues" which seem to persist longer than usual, or having a history of depression or other serious mental illness (O'Hara XXXX mple questions can help one decide whether a referral for an assessment is appropriate. One can begin to explore whether or not things are okay: "How are things going for you?" "How are you feeling?" "Looks like things have been tough lately." Resources should be identified in the area to direct individuals for referral, assessment, and possible treatment. Severely depressed women, especially those experiencing thoughts of suicide or infantcide, should be referred for an emergency psychiatric evaluation (Epperson, 1999). It is important for mothers to regain their ability to function. Using a variety of assessment instruments and asking questions about various factors such as financial and health status, as well as general well-being (Heneghan, Silver, Bauman, Westbrook, & Stein, 1998), health care providers can screen individuals for postpartum depression and provide appropriate treatment.
Co-morbidity, Associations, and Correlations with Maternal Depression
Like other forms of depression, maternal depression does not occur in isolation, but rather in conjunction with a complex interplay of co-occurring illnesses and experiences such as:
- High anxiety (APA, 1994; DaCosta, Larouche, Drista, & Brender, 2000; Heneghan et al., 1998; Kruckman & Smith, 1998);
- Obsessive-compulsive disorders (Kruckman & Smith, 1998);
- Post-traumatic stress, sometimes due to a traumatic birthing experience (Kruckman & Smith, 1998);
- Abuse, either living in a home where child abuse is occurring or having experienced physical or sexual abuse firsthand (Buist, 1998; Kinard, 1996);
- Chronic medical illnesses, especially those that impede mothers' activities (Heneghan et al., 1998; Lanzi, Pascoe, Keltner, & Ramey, 1999); and
- Low self-esteem (Beck, 1999; Kruckman & Smith, 1998).
- Alcoholism often co-occurs with both depression and anxiety. Depressed and anxious individuals often "self-medicate" with alcohol (Merikangas, Risch, & Weissman, 1994).
Certain demographic factors that may lead to chronic stress such as living in poverty or receiving public assistance, having less than a high school education, being unemployed and/or homeless, and having increased numbers of children or adults in a household, are also associated with maternal depression (Heneghan et al., 1998; Kinard, 1996; Kruckman & Smith, 1998; Lane et al., 1997; Lanzi et al, 1999; Windle & Dumenci, 1998):
Several aspects of the quality of a woman's family environment are associated with higher levels of maternal depression including:
- Perceived lack of support or parent assistance (Lanzi et al., 1999; Soliday, McCluskey-Fawcett, & O'Brien, 1999; Windle & Dumenci, 1998);
- Decreased marital satisfaction/feelings of emotional attachment toward a spouse (Bromberger, Wisner, & Hanusa, 1994);
- Elevated levels of parenting stress (Soliday et al., 1999; Windle & Dumenci, 1998);
- Role conflict or role changes (Kruckman & Smith, 1998);
- Decreased family cohesion (Windle & Dumenci, 1998); and
- The Impact of Maternal Depression on Parenting Behaviors
Depression appears to influence parenting behaviors and attitudes. A depressed mood affects mothers' perceptions and attributions of children's difficult behaviors (Boyle & Andrew, 1997; Briggs-Gowan, Carter, & Schwab-Stone, 1996; Fergusson, Lynskey, & Horwood, 1993; White & Barrowclough, 1998). These perceptions and attributions may influence parenting behaviors and intensify behavior problems in children.
Mothers who are depressed interact in different ways. Withdrawn or disengaged mothers generally provide inadequate stimulation for their newborns and infants, while intrusive mothers generally over-stimulate their children (Field, 1998; Hart, Jones, Field, & Lundy, 1999; Jones et al., 1997).
Duration and Timing of Maternal Depression: Developmental Consequences
Maternal depression is usually transient with no adverse consequences. Given the diversity in outcomes, postpartum depression is not inevitably a risk factor for problems in mother-child interactions or for child development. Some women feel better within a few weeks, while others feel depressed for many months or more. Some women get depressed during pregnancy or immediately following childbirth, while the onset of depression may take several weeks or more for others. In general, postpartum depression appears to persist over the course of several months. Effects of maternal depression vary by severity, chronicity (Frankel & Harmon, 1996), and timing of depression.
The more continuous, prolonged, and severe the mothers' depression, the greater the potential negative impact on the child. The duration and timing of maternal depression have an impact on children's social, emotional, cognitive, and behavioral development, as well as on maternal-child interactions and attachment, especially when the depressive episodes occur during infancy. Effects of the quality of mother-child interactions may be fewer if the mother is experiencing less severe and less chronic depression (Campbell & Cohn, 1997).
In general, infants of depressed mothers may be more irritable, less active, less responsive, and physically less developed than infants of non-depressed mothers (Field, 1997). Young children exposed to maternal depression in infancy are at higher risk for:
- Exhibiting behavior problems, such as hyperactivity, conduct disorders, and aggression (Beck, 1999; Boyle & Andrew, 1997; Fergusson et al., 1993; Murray, Sinclair, Cooper, Ducournau, & Turner; National Institute of Health [NIH], 1999);
- Having difficulties adjusting socially (Murray et al., 1999; Sinclair & Murray, 1998);
- Performing more poorly on measures of school readiness, expressive language and verbal comprehension (NIH, 1999);
- Developing symptoms that imitate the mother's depressed behavior (Stuart, 2000a), or developing episodes of depression (Merikangas, Weissman, Prusoff, & John, 1988), especially in cases of lower family functioning or in families exposed to multiple risk factors (Beardslee, Keller, Lavori, Staley, & Sacks, 1993; Ferro, Verdeli, Pierre, & Weissman, 2000; Shiner & Marmorstein, 1998; Windle & Durmenci, 1998); and
- Poorer cognitive development (although findings are contradictory) (Murray, Fiori-Cowley, Hooper, & Cooper, 1996; Murray, Hipwell, Hooper, Stein, & Cooper, 1996).
Recent data suggests that negative effects of postpartum depression on children may stem from maternal depressive symptoms during pregnancy. Studies of prenatal effects of maternal depression have found that newborns of mothers with depressive symptoms show disturbances in their behavior, physiology, and biochemistry, which are likely due to prenatal exposure to biochemical imbalances in their mothers (Field, 1998; Jones et al., 1998; Lundy et al., 1999).
Prevention
Taking preventative measures by attending to psychosocial risk factors is one way to lessen the likelihood that depression will develop (DaCosta et al., 2000). Simple interventions including mobilizing support systems, rearranging priorities, and planning ahead, could contribute to reduced emotional upset and reduce the risk for postpartum depression (Kruckman & Smith, 1998). It is imperative for people working with pregnant women, to watch for signs and symptoms of depression.
Treatment Implications
Depression is a very treatable illness. Even women with severe depression respond positively to treatment and less severe depression may go away without treatment. The earlier treatment begins, the more effective it is. Although treatment will not eliminate everyday stresses, it can boost a woman's ability to function and enjoy life.
Antidepressant medication and psychotherapy, used alone or in combination, are two treatments that can significantly lower the rate and severity of postpartum depression. If antidepressant medication is administered to mothers who are breastfeeding, the risks posed to the child need to be weighed against the risk of untreated depression (Stuart, 2000b). Many women are wary of taking medications, especially while breastfeeding and may refuse this form of treatment (APA, 1994). An alternative and effective treatment for mild to moderate depression is psychotherapy, which facilitates learning more effective ways of handling problems.
Other cost-effective and proven interventions include infant massage therapy, designed to positively modify the infant's mood; mother massage therapy or music therapy, intended to alter the depressed mother's mood; and interaction coaching, which teaches a mother to become more sensitive and aware of her infant's needs (Field, 1997, 1998).
Summary
Maternal depression manifests itself in many different ways. The consequences to both the mother and the child vary significantly depending on the severity, duration, and timing of the episode, and co-occurring illnesses or life experiences. If maternal depression is suspected, it is important to recognize the common signs of depression and to make a referral for an assessment and treatment, if necessary. Maternal depression is treatable.
**NOTE: The broad term "maternal depression" is used throughout this paper to encompass all manifestations of pre- and postpartum depression.
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