Psychological factors associated with persistent postnatal depression: past and current relationships, defence styles and the mediating role of insecure attachment style

Impact of defense style on brief psychotherapy of postpartum depression

In this study, we evaluated the impact of defense style (DS) on outcome and its relation to the therapeutic alliance. Women with postpartum depression were allocated to a brief psychotherapeutic intervention. To evaluate DS and the therapeutic alliance, the Defense Style Questionnaire and the Working Alliance Inventory were employed. The main outcome was the Edinburgh Postnatal Depression Scale score at end point; anxiety and retention in treatment were also evaluated. Fifty-nine patients were included; 46 completed the therapy and 65.4% responded (Edinburgh Postnatal Depression Scale score <10). Intense use of immature defenses was related to persistence of depression and anxiety symptoms at end point, even when controlled for potential confounders. Results tended to confirm a hierarchy of DSs independently of the alliance. Clinicians should be aware of possible differential responses to brief psychotherapies related to DS.

Postnatal depression and the original mother-child relationship: a prospective cohort study

BACKGROUND

Previous studies assessing the role of early mother-child relationship as a risk factor for postnatal depression have been cross-sectional and/or retrospective in nature.

AIMS

To examine associations between early mother-child relationship (assessed prospectively and retrospectively) and later risk of postnatal depression.

METHODS

Dataset from national 1946 birth cohort study; 1137 women at age 51, completed a modified version of the Bromley Postnatal Depression Scale.

RESULTS

Compared with women who did not experience maternal separation or recalled moderate to best level of care, women who experienced maternal separation for 3.5 days or more in early childhood and who felt they received a low level of maternal care were at higher risk of postnatal depression (odds ratio (95% CI): 2.4 (1.51-3.79), p=0.001); this relationship was robust to adjustment for current psychological status. Regular enuresis at age of 6 years (2.2 (1.01-4.90), p=0.05), and lack of emotional closeness in current maternal relationship (1.6 (1.01-2.46), p=0.04) were also associated with increased postnatal depression risk. Insufficient evidence was found for a link between other indicators of early behaviour and temperament (anxious, antisocial, or neurotic behaviour) and reported postnatal depression.

LIMITATIONS

Postnatal depression was assessed retrospectively using self-report, introducing potential bias in recall.

CONCLUSION

Women who experienced early maternal separation and recalled the lowest level of maternal care had a particularly high risk of postnatal depression. In the treatment and management of postnatal depression, the results support health professionals in their consideration of the woman's past and current relationship with her mother; both actual events and the woman's perceptions of them.

The 10-item Remembered Relationship with Parents (RRP10) scale: two-factor model and association with adult depressive symptoms

BACKGROUND

Dysfunctional parenting styles are associated with poor mental and physical health. The 10-item Remembered Relationship with Parents (RRP(10)) scale retrospectively assesses Alienation (dysfunctional communication and intimacy) and Control (overprotection by parents), with an emphasis on deficiencies in empathic parenting. We examined the 2-factor structure of the RRP(10) and its relationship with adult depression.

METHODS

664 respondents from the general population (48% men, mean age 54.6+/-14.2 years) completed the RRP(10), Parental Bonding Instrument (PBI), and Beck Depression Inventory.

RESULTS

The Alienation and Control dimensions of the RRP(10) displayed a sound factor structure, good internal consistency (Cronbach's alpha=0.83-0.86), and convergent validity against the PBI scales. No significant gender differences were found on the RRP(10) scales. Stratifying by RRP(10) dimensions showed that respondents high in Alienation and Control, for both father (33.3% vs. 14.5%, p<0.0001) and mother (42% vs. 12.9%, p<0.0001) items, experienced the highest levels of depressive symptoms compared with respondents low in Alienation and Control. While scoring high on Alienation or Control alone was also significantly and independently associated with depressive symptoms, scoring high on both Alienation and Control was most strongly connected with depressive symptoms for both father (OR=2.48, p<0.004) and mother (OR=5.34, p<0.0001) items.

LIMITATIONS

Cross-sectional study design.

CONCLUSIONS

The RRP(10) is a reliable and valid measure of remembered parental Alienation and Control. High Alienation and Control were independently related to increased risk of depressive symptoms. Given the brevity of the RRP(10), it can easily be used in epidemiological/clinical research on the link between the remembered relationship with parents and mental/physical health.

Is there an association between depressive and urinary symptoms during and after pregnancy?

Depressive symptoms and urinary symptoms are both highly prevalent in pregnancy. In the general population, an association is reported between urinary symptoms and depressive symptoms. The association of depressive and urinary symptoms has not yet been assessed in pregnancy. In this study, we assessed (1) the prevalence of depressive symptoms, over-active bladder (OAB) syndrome, urge urinary incontinence (UUI) and stress urinary incontinence (SUI) during and after pregnancy using the Center for Epidemiologic Studies Depression Scale (CES-D) and the Urogenital Distress Inventory (UDI) and (2) the association of depressive symptoms with urinary incontinence and over-active bladder syndrome during and after pregnancy, controlling for confounding socioeconomic, psychosocial, behavioural and biomedical factors in a cohort of healthy nulliparous women. Our data show a significant increase in prevalence of depressive symptoms, UUI, SUI and OAB during pregnancy and a significant reduction in prevalence of depressive symptoms, SUI and OAB after childbirth. UUI prevalence did not significantly decrease after childbirth. In univariate analysis, urinary incontinence and the OAB syndrome were significantly associated with a CES-D score indicative of a possible clinical depression at 36 weeks gestation. However, after adjusting for possible confounding factors, only the OAB syndrome remained significantly associated (OR 4.4 [1.8–10.5]). No association was found between depressive and urinary symptoms at 1 year post-partum. Only OAB was independently associated with depressive symptoms during pregnancy. Possible explanations for this association are discussed.

Predictive validation study of the Edinburgh Postnatal Depression Scale in the first week after delivery and risk analysis for postnatal depression

BACKGROUND

Postnatal depression is a major public health problem. The aim of this study is to validate the use of the Edinburgh Postnatal Depression Scale (EPDS) in the early postpartum, and to identify the markers for risk of postnatal depression.

METHODS

815 women filled out an EPDS and general information questionnaire between the third and the fifth day postpartum. The women with an EPDS score of >8 and a randomized control group from those with scores of <8 were contacted 8 weeks postpartum. 363 women therefore had a structured diagnostic interview by telephone at 8 weeks postpartum (MINI-DSM-IV), without knowledge of their EPDS scores, to screen for a major or minor depressive episode.

RESULTS

The sensitivity of EPDS was measured as 0.82 [0.78-0.86], with a positivity threshold of 9.5/30. For an estimated prevalence for all depressive episodes of 16.1%, the positive predictive value of EPDS was measured as 42.8% [39.1-46.5%]. Multivariate risk analysis using logistical regression identified the following as risk markers for postnatal depression: previous history of depression (postnatal or other), unemployment, premature delivery or stopping breast-feeding in the first month for non-medical reasons.

CONCLUSION

The use of EPDS between the third and fifth day postpartum is valid. An EPDS score of >10 should be completed by a clinical assessment and suitable management. The risk markers identified here are clinical indices that can be used for first-line early screening by non-psychiatric health workers.

Maternal attachment state of mind moderates the impact of postnatal depression on infant attachment

BACKGROUND

Empirical studies have revealed a significant, but modest association between maternal depression and insecure mother-child attachment. Across studies, however, a substantial number of mothers with depression are able to provide a sensitive caretaking environment for their children. This paper aimed to explore whether a mother's own state of mind regarding attachment moderated the association between postpartum depression and insecure mother-child attachment.

METHODS

Mothers (n = 111), mainly middle-class mothers, and their infants participated in a longitudinal study of postnatal depression, maternal attachment state of mind and child attachment. Depression was assessed using a diagnostic interview (at 4 and 12 months) and symptom checklists (at 4, 12 and 15 months). The Adult Attachment Interview was conducted at 12 months and the Strange Situation procedure at 15 months.

RESULTS

Mothers diagnosed as depressed were more likely to have an insecure state of mind regarding attachment. Infants of chronically depressed mothers were more likely to be insecurely attached; however, the relationship between maternal depression and child attachment was moderated by maternal attachment state of mind.

CONCLUSIONS

Results are discussed with reference to resiliency factors for women with postnatal depression and implications for intervention.

Postpartum depression without delivering a child?

OBJECTIVE

Depression in people related to delivering women is documented in their mates, but only anecdotal in other family members. We describe a case of depression in a woman who had previously experienced postpartum depression after the birth of her nephew.

METHOD

A clinical description of the case.

RESULTS

A 53-year-old woman, hysterectomized at age 47 years, was admitted for attempted suicide. She developed major depressive episode 1 month after her daughter had delivered a son. She had a past history of two postpartum depressive episodes clinically identical to the current episode. The episode resolved after 5 weeks. At 1-year follow-up, the patient is still asymptomatic.

CONCLUSION

Psychological and cultural factors were at play in this case more than hormonal and biopsychosocial ones.