Elsevier

Journal of Affective Disorders

Volume 246, 1 March 2019, Pages 522-529
Journal of Affective Disorders

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

https://doi.org/10.1016/j.jad.2018.12.124Get rights and content

Highlights

  • Not all women presenting risk for postpartum depression develop depressive symptoms.

  • At-risk women with no symptoms have higher levels of acceptance and self-compassion.

  • Acceptance processes are associated with a higher likelihood of reporting no symptoms.

  • Prevention interventions should consider the promotion of these processes.

Abstract

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.

Introduction

The transition to (new) parenthood is usually a demanding period for mothers because it entails an adjustment to lifestyle changes and new responsibilities (Slade et al., 2009). There is extensive research suggesting that the perinatal period is a time of increased risk for psychological problems (O'Hara & Wisner, 2014), and postpartum depression (PPD) is the most prevalent clinical condition in this period (rates range from approximately 13% in high-income countries to nearly 20% in developing countries; Fisher et al., 2012, O'Hara and McCabe, 2013 ). Additionally, the prevalence of postpartum anxiety disorders is 9.9% (Dennis et al., 2017), and comorbidity frequently occurs: approximately 35–40% of women presenting postpartum depressive symptoms also report comorbid anxiety disorders or symptoms (Farr et al., 2014). Depressive and anxiety symptoms have been shown to have pervasive consequences for the mother, the infant and mother-infant interactions (Field, 2010, Stein et al., 2014). Thus, the timely identification of women at risk of developing postpartum depressive and anxiety symptoms is very important to minimize such detrimental effects.

Over the last 20 years, there has been abundant research investigating the risk factors for PPD (for a review see Beck, 2001, Robertson et al., 2004). In a review regarding perinatal mental illness, a previous history of depression, stressful negative life events, poor marital relationship and a lack of social support were the most commonly reported risk factors (O'Hara & Wisner, 2014). However, despite being easily identified by practitioners, many of these risk factors have limited practical application because they refer mostly to contextual factors that are not easily modifiable through psychological interventions. Additionally, little is known about the factors that may reduce the likelihood of postpartum depressive and anxiety symptoms among at-risk women. As not all women presenting the commonly reported risk factors for PPD develop clinically relevant symptoms, it is important to examine which factors can modify the negative impact of risk, thereby buffering the emergence of postpartum depressive and anxiety symptoms and promoting a positive adjustment to this period.

The adjustment to motherhood is marked by a range of different internal experiences, including negative thoughts and emotions (Hall & Wittkowski, 2006). However, societal ideologies highlight that a normative response to motherhood is the presence of immediate and continuous feelings of happiness and joy (Sutherland, 2010). These expectations of motherhood may lead to women having more difficulties accepting their internal experiences, such as negative thoughts and emotions, when they do not reflect such ideals. As a result, they may learn to cope with these experiences by trying to control or avoid them, engaging in maladaptive strategies such as experiential avoidance, self-criticism and self-judgment, or negative metacognitive appraisals of their internal experiences. Although these strategies reduce unpleasant thoughts and feelings in the short term, they gradually increase unwanted private experiences (Hayes et al., 2006). Avoidance or control of internal experiences has been repeatedly linked to an increased impact of those experiences on one's wellbeing (e.g., Chawla & Ostafin, 2007). On the other hand, a few studies have indicated that the development of acceptance towards internal events is associated with lower levels of psychopathology, namely, depressive and anxiety symptoms (e.g., Fledderus et al., 2013). Thus, acceptance-focused strategies seem to play an important protective role in the development of psychological symptoms. A deeper focus on acceptance-focused strategies has recently emerged with the new developments of cognitive-behavioral therapies (i.e., third-wave cognitive-behavior approaches), such as Acceptance and Commitment Therapy (Hayes et al., 2006), Mindfulness-Based Cognitive Therapy (Segal et al., 2002) and Compassion Focused Therapy (Gilbert, 2010). Despite targeting different concepts, these approaches share several common features, namely the shift from previous assumptions focused on the content of internal experiences (e.g., changing thoughts and emotions), to a focus on the person's relationship to these experiences, fostering the development of acceptance- and compassionate-focused skills, such as psychological flexibility, more nonjudgmental appraisals of thought content and self-compassion.

Psychological flexibility can be seen as a self-regulatory and acceptance-focused process defined as the ability to be aware of the present moment and to willingly accept and experience thoughts and feelings that unfold without trying to control or avoid them while acting in a way that is consistent with one's values (Hayes et al., 2006). A few studies have emphasized its important long-term protective role (Bond et al., 2011, Fledderus et al., 2013, Shallcross et al., 2010). For example, in a community sample of women at risk of developing depression, Shallcross et al., (2010) found that higher levels of psychological flexibility protected women from developing depressive symptoms when facing elevated stress. Concerning the perinatal period, although the literature is scarce and there are no studies with at-risk postpartum women, some evidence shows that higher psychological flexibility is a significant contributor to higher maternal attachment, higher maternal responsiveness and lower depressive and anxiety symptoms (Evans et al., 2012).

Accepting internal cognitive experiences may also be important for women in the postpartum period. Several studies have demonstrated that negative metacognitive beliefs, such as beliefs about thoughts seen as uncontrollable and dangerous, may be particularly important in the prediction of depression and anxiety (Ryum et al., 2017, Yilmaz et al., 2011). In the postpartum period, this seems to be particularly relevant, and some studies have demonstrated the occurrence of these metacognitive appraisals (Fonseca and Canavarro, 2018, Hall and Wittkowski, 2006, Rodrigues et al., 2017). Likewise, qualitative research has shown that themes of loss of control over thoughts emerge among postpartum women (Beck, 1992). Therefore, it is likely that a more nonjudgmental appraisal of thought content—that is, the ability to accept and experience one's thoughts without judgment of their meaning or attempts at controlling them—could be associated with fewer depressive and anxiety symptoms. However, little is known about the influence of such acceptance-related processes in women's adjustment to this period, particularly among at-risk postpartum women.

Although related to acceptance-based processes, self-compassion may be understood as a conceptually different process. Self-compassion refers to the tendency not only to accept the individual's inner experiences, but also to be kind and compassionate to oneself when confronted with difficulties, as opposed to being self-judgmental, feeling isolated and overidentifying with personal difficulties (Neff, 2003). Self-compassion has been consistently associated with positive psychological outcomes (Akin and Akin, 2015, Barnard and Curry, 2011), and it is considered a potentially important protective factor for mental health. For example, in a nonclinical sample, Raes (2011) found that self-compassion predicted lower levels of depression. In the context of the perinatal period, self-compassion may be particularly relevant because higher levels of self-criticism have been associated with depressive and anxiety symptoms (Vliegen & Luyten, 2009), often accompanied by self-blame and feelings of guilt and shame (Coates et al., 2014, Dunford and Granger, 2017, Gutierrez-Zotes et al., 2016). Although there has been increasing interest in self-compassion, few studies have examined its role during the perinatal period, specifically with postpartum women presenting risk factors for PPD. A positive association has been found between higher levels of self-compassion and lower levels of depressive and anxiety symptoms among perinatal women (Felder et al., 2016, Fonseca and Canavarro, 2018). Moreover, Cohen (2010) found that greater self-compassion during pregnancy predicted significantly fewer depressive symptoms in the postpartum period.

Although the literature on the topic of acceptance and self-compassion is limited in the perinatal period, there are also some encouraging results from clinical intervention studies that have examined the effect of mindfulness- and compassion-based therapies on the reduction of depressive and anxiety symptoms, with community samples of perinatal women (e.g., Kelman et al., 2018), but also with samples of at-risk women (e.g., Dimidjian et al., 2016). Despite having different goals and not directly addressing the mechanisms of change (i.e., if changes in mindfulness skills or self-compassion are associated with changes in depressive symptoms), these interventions are theorized to target the enhancement of acceptance- and compassion-focused skills and have shown preliminary evidence of efficacy in reducing psychopathological symptoms (Dimidjian et al., 2016, Kelman et al., 2018).

Despite these important contributions, there is still a dearth of studies focusing on acceptance-based processes and self-compassion during the postpartum period. Bearing in mind that at-risk postpartum women are more likely to be the target and benefit from preventive interventions, the aim of the present study was to examine the differences in acceptance-based processes (psychological flexibility and nonjudgmental appraisal of thought content) and self-compassion among at-risk postpartum women presenting and not presenting clinically relevant depressive and anxiety symptoms. A second goal was to examine the added value of acceptance-based processes and self-compassion in the absence of depressive and anxiety symptoms. This knowledge is critical, as it may enable mental health professionals to develop and implement more targeted prevention interventions for women at risk of developing clinically relevant symptoms. Based on the literature reviewed, we hypothesized that at-risk women not presenting depressive and anxiety symptoms would have significantly higher levels of psychological flexibility and nonjudgmental appraisal of thought content as well as self-compassion and that these variables would be associated with a decreased likelihood of presenting clinically relevant symptoms.

Section snippets

Participants

The study sample comprised 185 postpartum women at risk of developing PPD (women who scored above the cutoff of 5.5 on the Postpartum Predictors Inventory-Revised [PDPI-R]), with a mean age of 32.58 years (SD = 4.90, range: 19–43). Most women were married/living with a partner (n = 156; 84.3%), were employed (n = 151; 81.6%), had completed higher education (n = 127; 68.6%) and had a medium socioeconomic status (n = 156; 84.3%). This was the first child for 67.6% (n = 125) of the women, and at

Sociodemographic and clinical information

Information regarding participants' sociodemographic (e.g., age, marital status, educational level, employment status) and clinical (e.g., prior history and treatment of psychopathological problems) characteristics was gathered through a self-report questionnaire developed by the authors.

Risk factors for postpartum depression

To identify women presenting risk factors for PPD, the postnatal version of the PDPI-R (Beck, 2002; Portuguese version [PV]: Alves et al., 2018;) was used. The factors assessed include marital status,

Data analysis

Data were analyzed using the Statistical Package for Social Sciences (IBM SPSS, version 23.0). Descriptive statistics and comparison tests (t tests and chi-squared tests) were computed for sample characterization. Based on the EPDS and HADS cutoff scores (EPDS ≥ 10; HADS ≥ 11), women were assigned to two groups, women presenting no clinically relevant depressive and anxiety symptoms and women presenting clinically relevant depressive and/or anxiety symptoms; t tests were used to compare the

Group differences and correlations among the study variables

Acceptance-based processes and self-compassion were compared between women not presenting (vs. presenting) depressive and anxiety symptoms (see Table 2). Women not presenting clinically relevant depressive and anxiety symptoms reported significantly higher levels in all the study variables. Moreover, large, significant and positive associations were found between psychological flexibility, nonjudgmental appraisal of thought content and self-compassion. Additionally, significant and negative

Discussion

The present study provides some preliminary findings that contribute to a richer understanding of the potential protective role of acceptance-based processes, namely, psychological flexibility and nonjudgmental appraisal of thought content, in the development of depressive and anxiety symptoms among at-risk postpartum women. Although the screening of psychosocial risk factors is important to identify women and prevent the negative consequences of PPD, the majority of our at-risk sample did not

Authors’ contributions

Fabiana Monteiro, Ana Fonseca, Marco Pereira and Maria Cristina Canavarro designed and conceptualized the study. Fabiana Monteiro and Stephanie Alves were responsible for conducting the data collection and for the integrity of the data. Fabiana Monteiro, Ana Fonseca and Marco Pereira undertook the statistical analysis. Fabiana Monteiro managed the literature searches and wrote the first draft of the manuscript. All authors critically contributed to and approved the final manuscript.

Funding/Support

Fabiana Monteiro and Stephanie Alves were supported by a doctoral grant from the Portuguese Foundation for Science and Technology (SFRH/BD/115585/2016 and SFRH/BD/102717/2014, respectively), Ana Fonseca was supported by a post-doctoral grant from the Portuguese Foundation for Science and Technology (SFRH/BPD/93996/2013) and Marco Pereira was supported by FCT Researcher Program (IF/00402/2014)

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgments

This study is part of the research project “Promoting maternal mental health: Applicability and effectiveness of an eHealth intervention for Portuguese postpartum women”, integrated in the research group Relationships, Development & Health of the R&D Unit Center for Research in Neuropsychology and Cognitive Behavioral Center Intervention (CINEICC) of the Faculty of Psychology and Educational Sciences, University of Coimbra (PEst-OE/PSI/UI0730/2014).

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