Dysfunctional beliefs towards motherhood and postpartum depressive and anxiety symptoms: Uncovering the role of experiential avoidance

The role of emotion regulation in perinatal depression and anxiety: a systematic review

BACKGROUND

Major depressive disorder and anxiety disorders are highly prevalent and comorbid during the perinatal period. Although research and clinicians agree that emotion regulation (ER) is an important transdiagnostic factor underlying both disorders in the general population, ER during the perinatal period has received less research attention. The aim of this systematic review was to assess the literature regarding the role of ten commonly studied ER strategies in the onset and maintenance of perinatal depression and anxiety in pregnant women and young mothers, using the Process Model of Gross (1998) as a theoretical framework.

METHODS

We searched four electronic databases with variations of the following key words: women; emotion regulation (i.e., behavioral approach, behavioral avoidance, problem solving, support seeking, distraction, rumination, reappraisal, acceptance, expressive suppression, and expressive engagement); perinatal period; and psychopathology. The aim was to identify peer-reviewed, and quantitative studies published between January 1999 and January 2023. Six articles were selected for analysis.

RESULTS

Similar ER strategies emerged as risk and protective factors in perinatal depression and anxiety. Overall, behavioral avoidance, distraction, rumination, and expressive engagement appeared as risk factors, while problem solving, emotional and instrumental support seeking, cognitive reappraisal, and acceptance, emerged as protective factors in the onset and maintenance of perinatal depression and anxiety. These findings align with previous research in perinatal community samples, as well as in non-perinatal clinical samples.

CONCLUSIONS

Our results support the role of ER as a transdiagnostic factor underlying both perinatal depression and anxiety. Clinicians are encouraged to implement ER strategies into the screening, prevention, and treatment of perinatal depression and anxiety. Further research is needed to strengthen these findings and to examine the role of emotion regulation during antenatal depression and anxiety more closely.

Experiential avoidance, thought suppression, meta-cognition, and body-checking among women during pregnancy and postpartum: Buffering effect of self-compassion

OBJECTIVE

The present study attempted to explore the psychological experiences of experiential avoidance, thought suppression, meta-cognition, self-compassion and body-checking during two stages of maternity (pregnancy and postpartum) among women embracing maternity for the first time.

METHODS

The study used a cross sectional correlational design and enrolled 306 women participants who were in their third trimester of pregnancy or of postpartum (pregnant = 154 [50.3%]; postpartum = 152 [49.7%]) with ages ranging between 20 and 35 years (M = 26.62; SD = 2.19). The data was collected using the Brief Experiential Avoidance Questionnaire (BEAQ); Thought Control Questionnaire (TCQ); Metacognitions Questionnaire (MCQ); Self-Compassion Scale (SCS), and Body-checking Questionnaire (BCQ). Data was subjected to statistical analysis using SPSS version 21.

RESULTS

A significant positive association was observed between experiential avoidance, thought suppression, meta-cognition, and body-checking while self-compassion showed reverse association with these variables. The body-checking outcome was significantly negatively predicted by self-compassionate attitude and positively by thought suppression in both groups (i.e., pregnant and postpartum). The experiential avoidance positively predicted body-checking among women in post-partum group only. Moreover, a mediating association of experiential avoidance and a moderating effect of self-compassion (self-kindness and common humanity) and meta-cognition (positive beliefs about worry and need to control thought) were also observed to moderate between thought suppression and body-checking outcomes.

CONCLUSION

The study concluded that experiential avoidance and thought suppression contribute in developing body-checking behaviors among women who are pregnant or at postpartum stage of maternity. In addition, self-compassion and meta-cognition moderate this association with self-compassion playing potential buffer.

Relationship between gender roles, motherhood beliefs and mental health

Gender roles, as social constructs, play a significant role in shaping individuals' beliefs and attitudes, influencing various aspects of life, including perceptions and expectations surrounding motherhood. These beliefs, acquired through culture and society, can have an impact on our mental well-being. This research consists of three independent studies conducted in the Mexican population. In the first and second studies, we extended the Attitudes Towards Gender Roles Scale and Motherhood Beliefs Scale and performed psychometric validation through exploratory and confirmatory factor analysis. The aim of including additional items in both scales was to update these attitudes and beliefs in Mexican culture to avoid the traditionalist bias in both instruments. Finally, the third study examined the relationship between the new versions of both scales and symptoms of depression, anxiety, and Positive Psychological Functioning as indicators of mental health in women and men with and without children. Our findings revealed a significant association between higher levels of traditional attitudes towards gender roles and traditional motherhood beliefs, as well as between non-traditional attitudes towards gender roles and non-traditional beliefs about motherhood. Interestingly, we observed that traditional attitudes toward gender roles were associated with lower anxiety and depression scores, while non-traditional attitudes were associated with higher levels of depression. Furthermore, individuals who embraced non-traditional attitudes towards both gender roles and motherhood beliefs tended to exhibit better psychological well-being in all subsamples. Additionally, women generally showed lesser alignment with traditional attitudes towards both gender roles and motherhood beliefs compared to men. However, women reported higher rates of depression and anxiety, along with lower psychological well-being scores, than their male counterparts. This highlights the significant influence that traditional cultural norms about gender roles and motherhood have on women's mental health, underscoring the need for a deeper understanding and reevaluation of these traditional constructs in society.

Experiential avoidance as a mediator of risk factors for higher order internalizing psychopathology in the perinatal period

OBJECTIVES

Perinatal psychopathology can be damaging. This study examined the strength of the associations between risk factors and all perinatal mood and anxiety disorder symptoms while assessing the mediating effect of experiential avoidance.

METHOD

Participants (N = 246) completed assessments during pregnancy (28-32 weeks) and the postpartum (6-8 weeks). Structural equation modeling (SEM) was used to examine associations between risk factors and latent factors: distress (composed of depression, generalized anxiety, irritability, and panic symptoms); fear (social anxiety, agoraphobia, specific phobia, and obsessive-compulsive); and bipolar (mania and obsessive-compulsive).

RESULTS

During pregnancy, past psychiatric history, anxiety sensitivity, maladaptive coping, and age were significant risk factors. In the postpartum, negative maternal attitudes and past psychiatric history were only risk factors for symptoms that composed distress. Experiential avoidance mediated the relation between maladaptive coping and symptoms that composed fear.

CONCLUSION

It is important to assess for psychological risk factors starting in pregnancy. This study identified critical risk factors that are associated with the underlying commonality among perinatal mood and anxiety symptoms. Some of the risk factors as well as the mediator are malleable (negative maternal attitudes, experiential avoidance), creating new possibilities for prevention and treatment of perinatal mood and anxiety disorder symptoms.

The Maternal Disintegrative Responses Scale (MDRS): Development and initial validation

OBJECTIVE

This study aimed to design and examine the validity of the Maternal Disintegrative Responses Scale (MDRS) to assess intrusive thoughts and dissociative experiences in the postpartum period.

METHOD

A convenience sample of 455 mothers whose babies were up to 12 months old completed the MDRS and a series of questionnaires assessing postnatal depression (Edinburgh Postnatal Depression Scale [EPDS]), childbirth-related post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and general symptoms of dissociation.

RESULTS

The final scale consists of eight items tapping two dimensions, intrusive thoughts and dissociative experiences, and displays good psychometric properties. Both factors were found to be related to EPDS, PTSD OCD, and general symptoms of dissociation. Primiparous women scored higher than multiparous women on both dimensions, and mothers of infants up to 3 months old scored higher on dissociative experiences than those whose infants were aged 4-12 months.

CONCLUSIONS

The MDRS can contribute to the theoretical and practical conceptualization and assessment of these phenomena.

Examining psychological inflexibility as a mediator of postpartum depressive symptoms: A longitudinal observational study of perinatal depression

Background

Depression is a common, serious complication during the postpartum period. Predictors of postpartum depression characterize who is at-risk for persistent symptoms. This study explored how psychological inflexibility affects depressive symptoms at 4 and 12 weeks postpartum.

Methods

Participants receiving prenatal care at a medical center were recruited during the second trimester. Participants (n = 180) completed online assessments and diagnostic interviews during the third trimester (≥ 28 weeks gestation), and at 4-, 8-, and 12-weeks postpartum. Online assessments measured psychological inflexibility (PI) and depressive symptoms, while diagnostic interviews measured lifetime history of depression.

Results

Mediation analysis examined pathways between 4-weeks postpartum depression, 8-weeks postpartum PI, and 12-weeks postpartum depression. Depressive symptoms at 4-weeks postpartum predicted PI at 8-weeks postpartum (β = 0.31, SE = 0.06, t(177) = 6.06, p < .001). Depressive symptoms at 4-weeks postpartum (β = 0.42, SE = 0.06, t(176) = 7.12, p < .001) and PI at 8-weeks postpartum (β = 0.32, SE = .08, t(176) = 4.09, p < .001) predicted depressive symptoms at 12-weeks postpartum. Depressive symptoms at 4-weeks, 8-week PI, and lifetime history of depression accounted for 42% of the variance in 12-week depressive symptoms (R2 = 0.42). The confidence interval of the indirect effect (0.04, 0.18) did not include zero, indicating significant mediation by PI.

Conclusions

PI mediated the relation between 4- and 12-weeks postpartum depressive symptoms when controlling for lifetime history of depression. Psychological inflexibility is a transdiagnostic target for future prevention and intervention research during the postpartum period.

Supporting routine cognitive reactivity assessment during the perinatal period: psychometric testing of the Chinese version of the Leiden Index of Depression Sensitivity

BACKGROUND

It is critical to find optimal forms to identify perinatal depression (PND) and its vulnerable factors and make them more applicable to depression screening. This study aims to evaluate the reliability and validity of the Chinese version of the Leiden Index of Depression Sensitivity (LEIDS-RR-CV) among perinatal women in China and determine the cut-off values for screening for high-risk depression.

METHODS

Women in their third trimester of pregnancy and six weeks postpartum completed the LEIDS-RR-CV and a diagnostic reference standard online. We assessed the LEIDS-RR-CV using classical test theory (CTT) and item response theory (IRT). We also assessed the test performance for cut-off scores using receiver operator characteristic analysis to further screen for high-risk depression at each time point.

RESULTS

In total, 396 (third trimester) and 321 (six weeks postpartum) women participated. Cronbach's alpha, two-week test-retest reliability, and marginal reliability for the scale were all greater than 0.8. It showed a five-factor model; the cut-off values were 58 (third trimester) and 60 (six weeks postpartum). The areas under the curve were acceptable (≥ 0.7), and the LEIDS-RR-CV was positively correlated with the total Edinburgh Postnatal Depression Scale (EPDS) score (r = 0.52 and 0.56, p = 0.00), indicating its predictive validity. An IRT analysis further confirmed its discriminative validity.

CONCLUSIONS

The LEIDS-RR-CV was found to be reliable, valid, and can be used to quantify cognitive reactivity among perinatal Chinese women and for screening for high-risk depression during this period.

A qualitative analysis of feelings and experiences associated with perinatal distress during the COVID-19 pandemic

Background

Rates of perinatal mental health difficulties (experienced during pregnancy and the 12-months postpartum) increased worldwide during the COVID-19 pandemic. In the UK, anxiety and depression were estimated to affect more than half of perinatal women during the first national lockdown. However, little is known about women’s qualitative experiences of distress. This study aimed to extend published quantitative findings resulting from the same data set (Harrison et al., Women Birth xxxx, 2021;  Harrison et al., J Reprod Infant Psychol 1–16, 2021) to qualitatively explore: 1) the feelings and symptoms associated with maternal perinatal distress during the COVID-19 pandemic; and 2) the associated sources of distress.

Methods

As part of an online survey during May 2020, 424 perinatal women responded to an open-ended question regarding a recent experience of distress. Qualitative data were analysed using an initial content analysis, followed by an inductive thematic analysis adopting a realist approach. Data were explored in the context of self-reported perinatal anxiety and depression symptoms.

Results

Initial content analysis of the data identified twelve distinct categories depicting participants’ feelings and symptoms associated with psychological distress. Despite the high rates of probable depression in the sample, women’s descriptions were more indicative of anxiety and general distress, than of symptoms traditionally related to depression. In terms of the associated psychosocial stressors, a thematic analysis identified five themes: Family wellbeing; Lack of support; Mothering challenges; Loss of control due to COVID-19; and Work and finances. Unsurprisingly given the context, isolation was a common challenge. Additionally, psychological conflict between maternal expectations and the reality of pregnancy and motherhood, loss of autonomy and control, and fears surrounding family health, safety, and wellbeing underlay many of the themes.

Conclusions

This study presents an array of feelings and symptoms expressed by perinatal mothers which may be useful to consider in relation to perinatal wellbeing. Furthermore, our data highlights several common sources of distress, including multiple COVID-19 specific factors. However, many were related to more general perinatal/maternal experiences. Our findings also point to considerations that may be useful in alleviating distress in pregnancy and early motherhood, including social support, realistic perinatal/maternal expectations, and support for those with perceived perinatal trauma.

A Blended Cognitive–Behavioral Intervention for the Treatment of Postpartum Depression: A Case Study

Postpartum depression is a highly prevalent mental health problem with harmful consequences for women, babies, and mother–infant relationships. Cognitive–behavioral therapy (CBT) is among the most effective treatment options for postpartum depression. However, a large number of postpartum women do not seek professional help, suggesting the need for new treatment delivery formats. The present article describes the application of Be a Mom Coping with Depression, a blended CBT treatment for postpartum depression, for a 31-year-old postpartum woman. The intervention was provided over a period of 13 weeks, integrating seven biweekly sessions with a psychologist and six sessions within an online program, and it is described in detail. A summary of the patient’s progress and the results obtained throughout treatment is reported. At the end of the intervention, a significant decrease in depressive and anxiety symptoms was observed, as well as increased perceived maternal self-efficacy, higher psychological flexibility, and higher self-compassion. This case study provides encouraging data for the preliminary evidence of the acceptability, feasibility, and efficacy of the Be a Mom Coping with Depression intervention in the reduction of depressive symptoms during the postpartum period. Advantages of this treatment format and implications for clinical practice and future research are discussed.

Qualitative, Interpretive Metasynthesis of Women's Experiences of Intimate Partner Violence During Pregnancy

OBJECTIVE

To describe the perspectives of women who experienced intimate partner violence (IPV) during pregnancy through a qualitative, interpretive metasynthesis.

DATA SOURCES

We searched 12 electronic databases to identify articles on qualitative studies pertaining to women's experiences of IPV during pregnancy. We searched Academic Search Complete, AgeLine, CINAHL Complete, Family Studies Abstracts, MEDLINE, PsycARTICLES, Psychology and Behavioral Sciences, PsycINFO, Social Work Abstracts, Health Source-Consumer Edition, Health Source-Nursing/Academic Edition, and Humanities Full Text for articles published from 2008 through 2018.

DATA EXTRACTION

We used inclusion and exclusion criteria to identify eight reports of qualitative studies that contained direct quotations in which women described their experiences of IPV.

DATA SYNTHESIS

We used a methodologic reduction to provide a theoretical context that helped us synthesize the data to five key themes: Pregnancy Escalates Abuse, Concern for Unborn Fetus, Importance ofSupport, My Child Saved Me, and Pregnancy Is a Catalyst for Reflection.

CONCLUSION

The results of our synthesis illustrate the unique perspectives of women who experienced IPV during pregnancy. Understanding these experiences can help health care providers assist pregnant women through enhanced screenings and education. Health care providers can also help women identify resources for emotional and financial support as they determine the best courses of action for themselves and their children.

What protects at-risk postpartum women from developing depressive and anxiety symptoms? The role of acceptance-focused processes and self-compassion

BACKGROUND

Not all women presenting risk factors for postpartum depression (PPD) develop depressive symptoms. Research has shown that acceptance-focused processes (nonjudgmental appraisal of thought content, psychological flexibility) and self-compassion play an important protective role in the development of psychological symptoms. However, considering the perinatal period, little is known about what variables can modify the negative impact of risk.

METHODS

The sample consisted of 185 postpartum women at risk of developing PPD (Postpartum Depression Predictors Inventory-Revised > 5.5). Data were collected regarding depressive (Edinburgh Postnatal Depression Scale) and anxiety symptoms (Hospital Anxiety and Depression Scale), psychological flexibility (Acceptance and Action Questionnaire-II), nonjudgmental appraisal of thought content (Postnatal Negative Thoughts Questionnaire) and self-compassion (Self-Compassion Scale-Short Form).

RESULTS

Women not presenting depressive and anxiety symptoms reported significantly higher levels of psychological flexibility, nonjudgmental appraisal of thought content and self-compassion than women presenting depressive and anxiety symptoms. Hierarchical logistic regression showed that women with higher levels of psychological flexibility (OR = 1.06, CI: 1.01-1.12) and nonjudgmental appraisal of thought content (OR = 1.33, CI: 1.15-1.53) had a significantly higher likelihood of not presenting depressive and anxiety symptoms.

LIMITATIONS

The limitations of this study were the cross-sectional design, the use of self-report questionnaires and the self-selected bias in recruitment.

CONCLUSIONS

This study emphasizes the important role of acceptance-based processes, suggesting that at-risk women who are more accepting of their private events may be more protected from developing psychological symptoms. Preventive interventions should consider the promotion of these processes to improve women's adjustment to this period.

Be a Mom, a Web-Based Intervention to Prevent Postpartum Depression: The Enhancement of Self-Regulatory Skills and Its Association With Postpartum Depressive Symptoms

Aim: Be a Mom is a self-guided, web-based intervention to prevent persistent postpartum depression symptoms [PPD], targeting both at-risk postpartum women and/or women presenting early-onset postpartum depressive symptoms (selective/indicated preventive intervention). Be a Mom is grounded on the principles of Cognitive-Behavior Therapy and incorporates the recent contributions of acceptance and compassion-based approaches (third-wave approaches) applied to the perinatal context. This study aimed to explore the processes underlying therapeutic change in the Be a Mom intervention, by: (1) exploring whether participation in the Be a Mom promotes the enhancement of self-regulatory skills (emotion regulation abilities, psychological flexibility and self-compassion) in comparison with women who did not participate in the program; and (2) exploring whether changes in self-regulatory skills are associated with changes in depressive symptoms, among women who participated in the Be a Mom program. Methods: A pilot randomized, two-arm controlled trial was conducted. Eligible women (presenting PPD risk-factors and/or early-onset PPD symptoms) were enrolled in the study and were randomly assigned to the intervention group (Be a Mom, n = 98) or to the waiting-list control group (n = 96). Participants in both groups completed baseline (T1) and post-intervention assessments (T2), including measures of depressive symptoms, emotion regulation abilities, psychological flexibility and self-compassion. Results: From baseline to post-intervention assessment, women in the intervention group showed a significantly greater decrease in the levels of emotion regulation difficulties (p < 0.001) and a significant greater increase in the levels of self-compassion (p < 0.001) compared to the control group. No significant differences were found concerning psychological flexibility. Moreover, a greater decrease in difficulties in emotion regulation and greater increase in self-compassion levels were significantly associated with a greater decrease in depressive symptoms, among women in the intervention group. Discussion: Be a Mom promotes the enhancement of women's emotion regulation abilities and self-compassion, and this seems to exert a protective effect in the presence of PPD risk factors (or early-onset symptoms) because it led to a reduction of depressive symptoms. By providing some insights into the processes that underlie treatment response to Be a Mom, this study highlights the important role of the targeted third-wave processes applied to the perinatal context.