Research reportPsychosocial predictors of depressive symptomatology level in postpartum women
Introduction
Postpartum depressive symptomatology is a common condition, with a prevalence of 20% to 30% (Cutrona, 1983). It causes important distress and has been associated with a variety of disturbances in mother-child interactions, and in the child's development (Field et al., 1990). These findings suggest that, although they do not meet diagnostic criteria, depressive symptoms are harmful in the context of postpartum adjustment. Consequently, the relevancy of studying their risk factors has been highlighted by several researchers (O'Hara et al., 1991).
Various psychosocial factors have been linked to postpartum depressive symptoms, whether above or below criteria for a depression diagnosis (Whiffen, 1992). However, it is difficult to establish the relative importance of these factors. Indeed, few studies have attempted to integrate these risk factors into a specific theoretical model of postpartum depression. Most studies which have, have suffered from limitations such as the use of a small sample size (Cutrona and Troutman, 1986), the inclusion of a limited number of risk factors (Cutrona and Troutman, 1986) or the omission of potentially important factors such as personal and family psychiatric history (Gotlib et al., 1991). In addition, interrelationships between risks factors of postnatal depression have scarcely been examined.
The present longitudinal study was designed to explore a multifactorial model for the prediction of the intensity of postpartum depressive symptoms. This model implied a vulnerability-stress conceptualization of depression (Brown and Harris, 1978) and integrated both maternity-focused factors and factors also studied in nonpostpartum depression literature.
Convincing evidence exists that maternity-focused factors play a major role in postpartum depressive symptomatology level. A most consistent finding is the important contribution of stressful life events occurring during pregnancy and the puerperium (Paykel et al., 1980). Stressors specific to maternity, such as obstetric complications, have also shown a relation to postnatal depression (Kumar and Robson, 1984). Another reasonably consistent finding is the importance of interpersonal relationships, that is social support and especially the marital relationship, in the transition to parenthood (Cowan and Cowan, 1988). Emotional well-being during pregnancy appears to be a major determinant in postpartum emotional adjustment. Prenatal depressive symptomatology has often been shown as the best predictor of postnatal depressive symptomatology (O'Hara et al., 1991). In addition, early psychoanalytic theorists have emphasized the major impact of some women's difficulties in adjusting to their maternal role (Bibring et al., 1961). Some support for this exists from several studies which have indicated that negative maternal attitudes, apprehension or ambivalence towards pregnancy and child rearing are associated with postpartum adjustment problems including depression (Grossman et al., 1980). Proximal stressors, emotional well-being during pregnancy and prenatal interpersonal relationships were given, in a descending order, a significant place in our model.
Several general factors have also been related to postpartum depression, and were included in our model. An association between dysfunctional cognitions and postpartum or general depression has been found in a number of studies (Barnett and Gotlib, 1988). More specifically, external locus of control or a sense of poor control over the environment and life events, has been linked to depressive symptomatology level and diagnostic state (Hayworth et al., 1980). Although less studied than proximal stressors, stressors occurring during the year preceding pregnancy could also be related to postnatal depression. This is consistent with the findings that chronic marked difficulties are associated with depression (Brown et al., 1986). Positive associations between psychiatric history and postnatal depression have been found by several authors (Watson et al., 1984), although not all (Kumar and Robson, 1984). Some studies have indicated that the quality of parental relationships during childhood and/or a history of early separation from parents are risk factors for postnatal depression (Kumar and Robson, 1984). Socioeconomic characteristics have been inconsistently associated with postnatal depression (Cox et al., 1982). Nevertheless, they were included in our model as they appear to be an important risk factor in general depression (Surtees et al., 1983).
Consistent with a vulnerability-stress model of postpartum depressive symptomatology, we included variables representing the interaction of depression vulnerability and stressors. Few studies of postpartum depression have examined such interactions and their results have been contradictory (Gotlib et al., 1991, O'Hara et al., 1991).
The proposed model was developed with a chronological perspective. It included three time periods: 1- the life time period preceding pregnancy 2- the first half of pregnancy and 3- the second half of pregnancy and puerperium. Several findings have suggested that postpartum depression is best conceptualized as an adjustment disorder (Whiffen, 1992). Accordingly, we hypothesized that proximal factors would contribute more importantly to postpartum depressive symptomatology than earlier factors.
Interrelationships between risk factors have seldom been examined in postpartum depression studies, whereas they have been described in the general depression literature (Harris et al., 1990). Several risk factors have been found to have an indirect effect on the susceptibility to general depression via their impact on other risk factors, such as dysfunctional cognitions and previous depressive episodes (Harris et al., 1990; Kendler et al., 1993). Accordingly, we explored whether stressors, poor interpersonal relationships, psychiatric history and poor family relationships during childhood would have an indirect effect on postpartum depressive symptomatology level through their contribution to dysfunctional cognitions and depressive symptoms during pregnancy.
The aim of the present study was to gain further insight into the factors influencing the intensity of postpartum depressive symptoms by testing a multifactorial model in 213 postpartum women. We predicted that proximal and maternity-focused variables would have a greater effect on the level of postpartum depressive symptomatology than distal and general factors. We also hypothesized that several variables would have both a direct and indirect effect on postpartum symptomatology level.
Section snippets
Sample
This study used a subset of data from a large research project examining risk factors for emotional disorders in childbearing women. Subjects were recruited during pregnancy through the obstetrics department of three urban French Canadian university hospitals and through the local media. To be eligible for participation, subjects had to be (a) French speaking (b) at least 20 years of age (c) involved in a marital or common-law relationship, and (d) primiparous or expecting a second child. Among
Results
Results of the path analysis (see Fig. 1) indicate that ten variables had a direct and/or indirect effect on postnatal depressive symptomatology level. Four variables showed a direct effect on postpartum depressive symptoms: (a) depressive symptom level during pregnancy, which showed the strongest association with the dependent variable (β=0.24, R2 change=0.15, p<.001)(b) lower occupational status (β=0.16, R2 change=0.04, p<0.01), (c) stressful life events preceding the prenatal assessment (β
Discussion
The results of this study indicated that the intensity of depressive symptoms at six months postpartum is influenced by risk factors in several domains. The contribution of general and more distal factors was at least as important as those proximal and specific to maternity. In that respect, a number of interesting and sometimes unexpected results emerged.
As predicted, stressors had a significant direct and indirect relationship to postnatal depressive symptomatology. However, a surprising
Acknowledgements
The research from which our data were derived was funded by Health and Welfare Canada (project 6605-2796-44). The current study was supported in part by grants from the Maisonneuve-Rosemont Hospital Research Centre, from the Department of Psychiatry of the University of Montréal and from the Maisonneuve-Rosemont Hospital Foundation. We would like to thank our colleagues from the Department of Psychiatry of the Maisonneuve-Rosemont Hospital for their encouragement in the conduct of this
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