Research report
Stability and change in level of maternal depressive symptomatology during the first postpartum year

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Abstract

Background: This study evaluated stability and change in the level of maternal depressive symptomatology over the course of the first postpartum year in a community cohort of 106 first-time mothers of full-term, healthy infants. Effects of diagnosed depression and infant gender were also assessed. Methods: At 2 months postpartum (intake), mothers were classified into one of two symptom groups on the basis of their total score on the Center for Epidemiological Studies–Depression Scale (CES-D): high (CES-D score ≥16, 46%) or normative (CES-D score=2–12, 54%). Mothers completed the CES-D again at 3, 6, and 12 months postpartum. At 12 months, maternal diagnostic status for major depression and related disorders was evaluated using the Diagnostic Interview Schedule-III–Revised. Results: Mothers in the High symptom group at intake continued to have significantly higher CES-D scores at 3, 6, and 12 months than mothers in the Normative symptom group at intake, and a third in the High symptom group at intake had a subsequent CES-D score above the clinical cutoff (≥16). Maternal CES-D scores were significantly correlated across visits. In regressions controlling for diagnostic status and infant gender, mothers’ CES-D score at the most recent prior assessment contributed significant unique variance to mothers’ CES-D score at each subsequent assessment. CES-D scores were higher at 3 months if mothers had diagnosed depression and were parenting a son, and higher at 12 months if mothers had both diagnosed depression and a prior, high CES-D score. Limitations: Findings may not generalize to multipara or high-risk cohorts. Conclusions: First-time mothers with high levels of depressive symptomatology at 2 months postpartum (especially those with diagnosed depression) are at increased risk of continuing to experience high levels of depressive symptomatology throughout the first postpartum year. Implications for preventative intervention services are discussed.

Introduction

Maternal postpartum depression is a prevalent public health problem. Approximately 8–15% of postpartum women in community samples report clinically significant levels of depressive symptoms (Cooper et al., 1988, Murray, 1992, O’Hara et al., 1990). Given the deleterious effect of chronic maternal depressive mood on maternal and child functioning (see reviews by Cummings and Davies, 1994, Downey and Coyne, 1990, Field, 1995, Tronick and Weinberg, 1997), surprisingly few investigators have evaluated the stability of maternal depressive symptoms during the first postpartum year or assessed whether factors such as a pre-gravid history of diagnosed depression or chronic depression affect the stability and level of maternal postpartum depressive symptoms.

Evidence for a moderate level of stability in maternal depressive symptoms during the first three years postpartum, as assessed with the Center for Epidemiological Studies–Depression Scale (CES-D, Radloff, 1977), was reported in a large national longitudinal study of mothers ranging in degree of socio-demographic risk (NICHD Early Child Care Research Network, 1999). Correlations of CES-D scores over time ranged from 0.41 to 0.58. However, these correlations may have been due, in part, to stability in these women’s heterogeneous risk profiles, since maternal depression is known to be exacerbated by exposure to co-morbid risk factors such as chronic poverty, social isolation, drug abuse, or poor maternal or infant health (Lyons-Ruth et al., 1990, Teti et al., 1990). Very few studies have evaluated the point prevalence and stability of maternal depressive symptomology in cohorts of postpartum women that are unconfounded by co-morbid social and medical risk factors.

A notable exception is the research of Campbell and colleagues (Campbell and Cohn, 1997, Campbell et al., 1992, Campbell et al., 1995), who evaluated the course of clinically significant depression in a selected low-risk cohort of first-time, mostly middle-class mothers from 2 to 24 months postpartum. Only 13% of mothers who met diagnostic criteria for major or minor depression at 2 months postpartum continued to meet diagnostic criteria for depression by 24 months. However, a third continued to report subclinical levels of depressive symptomatology, suggesting a moderate degree of stability in these mothers’ depressed mood and affect over time, even in the absence of clinically significant depression.

Similarly, Cooper et al. (1988) reported significant remission in diagnosed depression over the course of the first postpartum year in a large community sample of mothers in London. Although 8.7% of mothers in that cohort received a diagnosis of depression at 3 months postpartum, one-third continued to meet diagnostic criteria for depression by 6 months postpartum, and a very small number were still depressed by 12 months postpartum. However, the stability of the level of mothers’ maternal depressive symptomatology in this cohort was not reported.

Little is known about how a history of diagnosed depression affects the level and stability of maternal depressive symptomatology during the first postpartum year. In studies of the course of depression in non-postpartum samples (Gonzales et al., 1985, Keller and Shapiro, 1981), patients with a history of chronic depression, including those with co-morbid psychiatric diagnoses and those with chronic low-level depressed mood between depressive episodes, were more likely to experience longer bouts of depression. Accordingly, some investigators have argued that the high levels of depressive symptoms experienced by some mothers in the postpartum period may stem from a pre-pregnancy history of major depression (Cooper and Murray, 1995, O’Hara, 1997). One might therefore expect mothers with a pre-gravid history of depression (even in the absence of diagnosed depression in the postpartum period) to experience higher levels of depressive symptoms during the first postpartum year than mothers without a psychiatric diagnosis. One might also expect that women with chronic depression (e.g. multiple depressive episodes occurring both prior to pregnancy and after the birth of the child) would report higher levels of depressive symptoms during the first postpartum year than mothers with only a pre-gravid history of depression (Campbell et al., 1992). In support of this, a few investigators (Murray et al., 1993, Weinberg et al., 2001) have reported that maternal depression during the postpartum period is associated with maternal and child maladaptation, whereas pre-gravid depression in the absence of postpartum depression is not.

Section snippets

Objectives and hypotheses

The primary goal of this study was to evaluate stability and change in the level of maternal depressive symptomatology during the first postpartum year in a community sample of first-time, middle-class, otherwise healthy mothers. Depressive symptomatology was measured using the CES-D at intake (2 months postpartum) and again at 3, 6, and 12 months postpartum (see Section 3 for details).

Three questions were evaluated in addressing our primary goal: (1) Would mothers who reported high levels of

Subjects

Subjects were participants in one of two larger prospective longitudinal studies concerned with the effects of maternal depressive symptoms on maternal adaptation and maternal and infant behavior during the first postpartum year (RO1MH45547, RO1MH43398, EZ Tronick, PI). With the exception of their depressive symptomatology, subjects in both studies met identical low medical and social-demographic risk inclusion criteria. These criteria allowed us to evaluate the stability and level of

Sample characteristics

The sample consisted of a community cohort of 106 first-time mothers and their healthy, term infants. Mothers were all married or living with the baby’s father, from working- to upper-middle class backgrounds (average Hollingshead socioeconomic index=55, S.D.=8, range=28–66; Hollingshead, 1975), and mostly Caucasian. On average, mothers were 32 years old (S.D.=3, range=25–40) and had received an average of 16 years of education (S.D.=1.8, range=12–23). Sixty infants (57%) were male.

Discussion

This study evaluated stability and change in the level of maternal depressive symptomatology over the course of the first postpartum year in a community cohort of first-time mothers. Effects of a history of diagnosed depression and infant gender on the level of maternal postpartum depressive symptoms were also assessed.

Findings indicated that mothers who had a high (≥16) CES-D score at 2 months postpartum (intake) were significantly more likely to have a higher CES-D score again at 3, 6, and 12

Acknowledgements

The research presented in this report was supported in part by two grants from the National Institute of Mental Health (RO1MH45547, RO1MH43398, EZ Tronick, PI). The authors thank the mothers and infants for their loyal participation in these studies and acknowledge the valuable research assistance of Kate Fagan, Holly Foster, Grace Brilliant Gustafson, Paula Ivey, Margaret Kelsey, Yana Markov, Snaltze Charlot Pierre, April Prewitt, Jennifer Scott-Sutherland, Paul Stansbery, and others at the

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