Series in Psychopathology. Series Editor Lauren B. Alloy

Transcription

1 Series in Psychopathology Series Editor Lauren B. Alloy

2 Michael W. O'Hara Postpartum Depression Causes and Consequences With a Foreword by Lee S. Cohen, M.D. With 22 Illustrations Springer-Verlag New York Berlin Heidelberg London Paris. Tokyo Hong Kong Barcelona Budapest

3 Michael W. O'Hara, Ph.D. Department of Psychology The University of Iowa Iowa City, IA Library of Congress Cataloging-in-Publication Data O'Hara, Michael W. Postpartum depression: causes and consequenceslmichaei W. O'Hara. p. cm. Includes bibliographical references and index. ISBN ISBN Postpartum depression. I. Title. [DNLM: 1. Depression-etiology. 2. Puerperal Disorderspsychology. 3. Psychotic Disorders. 4. Pregnancy-psychology. 5. Depressive Disorder-therapy. WM p 1994] RG '6-dc Printed on acid-free paper Springer-Verlag New York, Inc. Softcover reprint of the hardcover 1 st edition 1995 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production coordinated by Chernow Editorial Services, Inc., and managed by Francine McNeill; manufacturing supervised by Jacqui Ashri. Typeset by Best-set Typesetter Ltd., Hong Kong ISBN-13: DOl: / e-isbn-13:

4 To Jane, Jeffrey, and Andrew for their love and support and to my parents, Bill and Colleen

5 Foreword What is the prevalence of mood disorders during pregnancy and the postpartum period; does the prevalence vary compared to nonchildbearing women? What are the psychosocial and neurobiologic factors that predict risk for postpartum mood disorders? Postpartum Depression: Causes and Consequences by Michael W. O'Hara synthesizes a series of efforts to address these and other difficult questions. It is a clear, cohesive, and carefully prepared work, which serves not only as a review of more than a decade of research, but also as a charge for future investigation regarding unanswered questions about postpartum mood disturbance. Depression after childbirth is one of the most prevalent complications in modern obstetrics. Nonetheless, the subject of postpartum mood disorders remains understudied. Some investigators pursue nosologic debates regarding the extent to which postpartum depression should be considered a discreet diagnostic entity. Others have tried to identify biologic or psychosocial factors that are uniquely associated with puerperal illness. More recent efforts have begun to focus on the need to identify predictors of risk for developing depression during pregnancy and the postpartum period. Identification of women "at risk" can lead to prophylactic treatment strategies that attenuate such risk, thereby limiting morbidity associated with untreated depression and the impact of maternal psychiatric disorder on child development. The current volume is an elegant review not only of the work performed by Michael W. O'Hara and his colleagues at the University of Iowa, but also of the dozens of investigations designed to answer questions regarding the causes and sequalae of postpartum mood disturbance. The book is greater than the sum of its parts. On the one hand, it is about the relationship between childbirth and mood disorders. On another level, it is about replacing myths regarding pregnancy and the puerperium. This is achieved by subjecting difficult questions to rigorous and systematic investigation. The book outlines the methodologic and conceptual framework from which a number of scientific investigations have been derived in an effort to integrate more clearly the factors that potentially contribute to postpartum mood disturbance. The scope of research reviewed in the text is vast. Findings of similar rates of mood disorder in childbearing and nonchildbearing women are vii

6 viii Foreword reviewed, and the implications are discussed. Pregnancy and the puerperium may not impact on the natural course of mood disorder, and thus, the postpartum period does not appear to be a period of particular risk for the development of nonpsychotic major depression. What does appear to place women at risk for postpartum depression, however, is a personal or family history of depression. This finding, which is noted in several of the studies discussed in the book, has extraordinary implications given the prevalence of mood disorder in women during their childbearing years and the extent to which these-populations of women "at risk" frequently go unidentified. The absence of conclusive findings of specific neuroendocrine dysregulation associated with puerperal illness or psychosocial variables that uniformly correlate with postpartum depression combined with the predictive value of such variables as personal or family history of depression ultimately lead the reader to conclude that mood disturbance during childbearing is indeed a complicated affair. It is conceivably a phenomenon derived from a convergence of biologic and psychosocial factors that interact with preexisting vulnerability. Perhaps the most compelling aspect of Postpartum Depression: Causes and Consequences is found not in a single table or statistical analysis, but rather in the implied mandate that springs from the studies describednamely, to screen for so prevalent a disorder (and for factors that may predict its emergence) in such nonresearch settings as primary-care medicine and obstetrics and gynecology. If personal and family history of mood disorder as well as past history of postpartum depression appears to be strongly associated with depression during pregnancy and the puerperium, then there is a clear need to screen for mood disorder in settings in which women seek medical treatment. Screening of women at potential risk for mood disturbance during pregnancy and the postpartum period is the first step toward identification of these women and toward providing closer follow-up and early intervention, if necessary. Our ability to predict particular vulnerability to the onset of mood disturbance during pregnancy or the puerperium also opens the door to the possibility of studying prophylactic strategies to attenuate such risk. Appropriate screening before, during, and after pregnancy may help identify women with mood disturbances responsive to a wide spectrum of therapies. Identification of greater numbers of women with postpartum psychiatric illness must be complemented by intensive efforts to treat these women. Risks of untreated mood disorder including chronic affective disorder are well described. Of equal concern is the evolving evidence suggesting an adverse impact of maternal mood disorder on child development. If the current text helps legitimize puerperal illness, then our next task is to insist on its treatment. To that end, this volume clearly helps pave the way. Lee S. Cohen, M.D. Boston, Massachusetts

7 Acknowledgments The research described in this volume was supported by National Institute of Mental Health Grant MH39383 to Michael W. O'Hara. The writing of this volume was supported by the University of Iowa Faculty Scholar program. Many colleagues and students collaborated on this research and made significant contributions to it, including Ellen Zekoski, Laurie Philipps, Ellen Wright, Michael Varner, Janet Schlechte, and David Lewis. Expert consultation for various aspects of this research was provided by Daniel Russell, Jon Lemke, Don Routh, and Linda Whitaker. I also thank Mary Walling for her critical reading of an earlier version of this volume. Finally, I wish to thank all of the women who so generously gave of themselves and their time. This work would not have been possible without them. Michael W. O'Hara Iowa City, Iowa ix

8 Contents Foreword... vii Acknowledgments... ix 1 Introduction Preliminary Work Background and Methods Psychopathology Across Pregnancy and the Puerperium Adjustment, Social Support, and Life Events Across Pregnancy and the Puerperium Depression During Pregnancy Postpartum Blues Postpartum Depression Summary and Implications Appendix A: Childcare Stress Inventory Appendix B: Peripartum Events Scale 197 Appendix C: Social Support Interview 201 References Index xi