Depession. Blues and Postpartum. 1< ;As CLINICAL STUDIES. July/August 1992 J O G N N 287

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1 1< ;As CLINICAL STUDIES CHERYL TATANO BECK, DNSc, CNM MARGARET A. REYNOLDS, PHD, RN PATRICIA RUTOWSKI, RNC, MSN Blues and Postpartum Depession Objective: To investigate the relationship between maternity blues and postpartum depression in mothers discharged early from the hospital and those discharged afer the customary length of hospital stay. Design: A descriptive correlation design. Setting: 550-bed community and teaching hospital in the midwestern United States. Participants: 49 privately paying, primiparous, American born women, 18 years of age or older, with uncomplicated pregnancies and vaginal deliveries of healthy neonates weighing 2,600-4,000 g. Measures: Stein Maternity Blues Scale and Beck Depression Inventory were used to collect data. Results: No signijicant diferences found between the two groups of mothers; signijicant relationships found between maternity blues at 1 week afer delivery and postpartum depression at 6 and 12 weeks after delivery. Conclusions: Early discharge appears to pose no threat to psychologic well-being. Primiparas experiencing more severe maternity blues are at increased risk for postpartum depression. Accepted: January tudies undertaken in the 1980s (Avery, Fournier, Jones, & Sipovic, 1982; Lemmer, 1986) confirmed findings of studies carried out in the 1970s (Mehl, Peterson, Sokolowsky, & Whitt, 1976; Yanover, Jones, & Miller, 1976) that early postpartum discharge is a safe, satisfying, and cost-effective alternative to the customary length of hospital stay for low-risk mothers and their neonates. However, the studies of the past decade evaluated the physical safety of mothers discharged early and not their psychologic safety. Whether there is a significant difference in the incidence of maternity blues and postpartum depression between mothers who choose early discharge and mothers who stay the customary hospitalization period of 3 days has yet to be investigated. In Great Britain, evidence is mounting of an increased risk of postpartum depression in women who have experienced maternity blues (Paykel, Emms, Fletcher, & Rassaby, 1980; Stein, 1980). The relationship between maternity blues and postpartum depression has not been studied in the United States. If a correlation exists between maternity blues and postpartum depression, it would be clinically significant. Nurses could intervene with mothers experiencing severe blues to help prevent the development of postpartum depression and to facilitate a healthy maternalchild relationship. Research has consistently demonstrated tbat maternal depression has an adverse effect on children s general behavioral and developmental functioning (Cogill, Caplan, Alexandra, Robson, & Kumar, 1986; Weissman et al., 1984). Specific problems, such as sleep disturbances, also have been reported (Richman, 1981). A mother s depression may interfere with her ability to respond appropriately to her infant. Mothers experiencing postpartum depression have been reported to be less spontaneous, less happy, less vocal, and less close with their 4-month-old infants (Sameroff, Siefer, & Zax, 1982). At 2 months of age, infants of depressed mothers were found to be less competent cognitively and to express more negative emotions than infants of nondepressed mothers (Whiffen & Gotlib, 1989). Recently, Zuravin (1989) reported that moderately depressed mothers were at increased risk for physical aggression with their children, while severely depressed mothers were at increased risk for verbal aggression. The purposes of this study were (a) to investigate the relationship between the incidence of maternity blues during the 1st week after birth and postpartum depression in primiparas at 1, 6, and 12 weeks postpartum and (b) to determine differences in the incidence and severity of these two conditions between July/August 1992 J O G N N 287

2 C L I N I C A L S T U D I E S In Great Britain, evidence is mounting of an increased risk of postpartum depression in women who have experienced maternity blues. women experiencing early hospital discharge and those with customary lengths of hospital stay. literature Review Maternity blues is a transitory phenomenon of mood changes that begins within the first few days after delivery and can last 1-10 days or longer. It is characterized by depression, tearfulness, anxiety, clouding of consciousness, irritability, headache, and lability of mood. In the United States, the incidence of maternity blues during the 1st week postpartum has been reported to be from 58% (Buesching, Glasser, & Frate, 1986) to 67% (Yalom, Lunde, Moos, & Hamburg, 1968). There is little agreement on which days the symptoms of the blues occur most frequently or on which days they are most severe. Handley, Dunn, Waldron, and Baker (1980), for example, did not find a peak incidence of the blues during the 1st week postpartum, while Stein (1980) reported that depression, crying, headaches, dreaming, irritability, and restlessness peaked around 4 to 6 days postpartum. Postpartum depression is similar to a minor or major depressive episode, as defined by the Research Diagnostic Criteria of Spitzer, Endicott, and Robins (1978). The clinical signs and symptoms of postpartum depression are comparable to those of ordinary depression. The U.S. incidence of postpartum depression in mothers during the first 3 months after delivery has been reported to be as low as 10% (Saks et al., 1985) and as high as 26% (Atkinson & Rickel, 1984). In the United States, researchers have been testing predictive models of postpartum depression for the past decade. The predictor variables of prenatal depression, cognitive-behavioral measures, and stressful life events have been reported to account for 50% of the variance in postpartum depression (O Hara, Neunaber, & Zekoski, 1984). A mediational model of postpartum depression employing social support, infant temperament, and parenting self-efficacy is supported in Cutrona and Troutman s (1986) study of 55 married women. Other studies attempting to predict postpartum depression have revealed, as significant predictive factors, hostility in pregnancy (Bridge, Little, Hay- worth, Dewhurst, & Priest, 1985; Little, Hayworth, Benson, Bridge, Dewhurst, &Priest, 1982), marital dissatisfaction (Whiffen, 1988), and depression during pregnancy (Bridge et al., 1985; O Hara, Rehm, & Campbell, 1982; O Hara et al., 1984). In summarizing the research on the prediction of postpartum depression, Boyer (1990) compiled a list of 15 risk factors that may be useful in clinical practice. Included are a history of mental illness, feeling unloved by a partner, and financial problems. Evidence of an increased risk of postpartum depression in women who experienced postpartum blues has been reported. Paykel et al. (1980) found that, in the absence of recent stressful life events, the blues were significantly associated with postpartum depression 6 weeks after delivery in a sample of 104 mothers. Stein (1980) reported that women who had experienced the blues scored significantly higher on a depression rating scale at 3 months postpartum than mothers who had not experienced the blues. In a study of 81 mothers, Kendell, McGuire, Connor, and Cox (1981) found that women who became depressed 3 to 5 months postpartum had significantly higher depression and lability ratings during the 1st week after birth than mothers who did not become depressed. Cox, Connor, and Kendell (1982) reported that women with severe maternity blues were at risk of persistent depressive symptoms 3 and 5 months after delivery. Sample Subjects were recruited from a 550-bed community and teaching hospital in the midwestern United States. The convenience sample consisted of 49 primiparous, American-born women, 18 years of age or older, who had uncomplicated pregnancies and vaginal deliveries. Only private patients who had delivered full-term (38 to 42 weeks), normal healthy infants weighing 2,600-4,000 g were included in the study. The researchers were striving for a homogeneous sample with the fewest number of additional problems to influence the incidence of maternity blues and postpartum depression. Mothers were excluded from the study if they had previous or current psychiatric disorders, basal metabolic-related health problems, or multiple births. Two groups composed the sample. The first group consisted of 36 new mothers who stayed the customary 3-day hospitalization period. The second group consisted of 13 mothers who had early discharges, leaving on the 1st or 2nd postpartum day. During the data collection period, the hospital s early discharge 288 J O G N N Volume 21 Number 4

3 Maternity Blues and Postpartum Depression program consisted of mothers who were being discharged anytime before their 3rd day postpartum. One third (4) of the mothers who were discharged early left the hospital within 24 hours of delivery. The rest of the mothers who were discharged early left on the 2nd day after delivery. The 1st day postpartum was defined as the day beginning at 12:Ol a.m. on the day after delivery. Whether to be discharged early was the mother s choice. If the mother desired an early discharge and her physician agreed, then she was discharged early. Procedures Four research assistants collected data over a 6-month period from July to December. All the research assistants were trained together in sessions on the data collection procedures. The research assistants were neither nurses nor in any related health profession, to ensure that they would not become confounding variables. The researchers believed that, if the research assistants had been nurses, the mothers might have reported a lower incidence of maternity blues because they knew that, after they were discharged from the hospital, they could look forward to a daily visit by a nurse who would be collecting their completed questionnaires. Every woman who met the sample criteria was asked on her 1st day after delivery to participate in the study. The research assistant introduced herself to each prospective subject and explained the research project. Women who agreed to participate signed a consent form. During the 1st week after delivery, every evening just before retiring to bed, each mother completed Stein s Maternity Blues Scale (Stein, 1980). Each evening, a research assistant would go to the hospital or to the mother s home to collect the completed questionnaire from the day before and leave her another for that evening. All the research assistants were instructed not to discuss anything during these visits with the mothers regarding their maternity blues or postpartum depression. Subjects completed the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) on the evening of the 7th day postpartum. The Beck Depression Inventory also was mailed to each mother at 6 and 12 weeks after delivery. The women mailed the completed questionnaires back to the researchers. Instruments Stein s Maternity Blues Scale (Stein, 1980) consists of a 13-symptom, self-rated scale. The symptoms listed are depression, crying, anxiety, tension, restlessness, exhaustion, dreaming, appetite, headache, irritability, poor concentration, forgetfulness, and confusion. Stein s scale provides an overall severityscore for each day and also an average score for the entire week. The score for the first 8 symptoms is indicated by the number circled. The number of choices for each symptom varies. For example, the choices for the symptom of tension range from 0 to 2, with 0 indicating I feel calm and relaxed; 1, I feel somewhat tense; and 2, I feel very tense. The choices for the symptom of crying range from 0 to 4, with 0 indicating I do not feel like crying; 1, I feel as if I could cry but have not actually cried; 2, I have shed a few tears today; 3, I have cried for several minutes today but for less than half an hour; and 4, I have cried for more than half an hour. Each of the last 5 symptoms is given a score of 1 if it is present and 0 if it is not. The sum of the scores for all the symptoms provides the daily score, which can range from 0 to 26. A daily score of 0 to 2 indicates the absence of maternity blues, 3 to 8 is reflective of mild to moderate blues, and 9 or higher indicates severe maternity blues. Acceptable levels of reliability and validity for this scale have been reported (Stein, 1980). The Beck Depression Inventory (Beck et al., 1961) consists of 21 categories of symptoms and attitudes. Each category describes a specific behavioral manifestation of depression and consists of a graded series of four statements that range in severity from neutral (score, 0) to maximum (score, 3). The total possible score ranges from 0 to 63. The reliability and validity of the Beck Depression Inventory are well established (Reynolds & Gould, 1981; Strober, Green, & Carlson, 1981). Based on Beck s (1978) guidelines, a score of 9 was the cutoff point beyond which a case of postpartum depression was diagnosed. Women scoring 10 to 15 points were considered mildly depressed, those scoring 16 to 19 points mildly to moderately depressed, those scoring 20 to 29 points moderately to severely depressed, and thosescoring 30 to 63 points severely depressed. Results Subjects Chi-square analysis and Student s t-test revealed that the group of mothers discharged early and the group discharged after the customary length of stay of 3 days did not differ significantly on any of the following demographic variables: race, marital status, income, age, and education (see Table 1). Educational level was measured as the number of years of formal education a subject had completed. The two groups of mothers differed significantly (t = -9.98, p < 0.001) on the length of their hospitalization. Mothers who were discharged after the customary length of stay remained in July/August 1992 J O G N N 289

4 C L I N I C A L S T U D I E S Table 1. Comparison of Demographic Characteristics of Mothers Discharged Early and Mothers Discharged After Customary Length of Stay Customary Type of Dlscbarge Early Variable N % N % Race White Black Marital status Married Single Education Age Mean SD Mean SD the hospital after delivery for a mean of 69 hours (SD = l0.63), while the mean for the mothers discharged early was 33 hours (SD = 12). Of the 13 who were discharged early, 6 had planned a short stay before admission to the hospital, while 7 had not. Stein Maternity Blues Scale The daily mean scores for both groups of mothers fell in the range of mild to moderate maternity blues (see Figure 1). Repeated analysis of variance on the measures used in the study revealed no significant differences in the daily maternity blues scores for the two groups of mothers during the 1st week after delivery. A profile analysis of the mean maternity blues scores for both groups over the first 7 days postpartum was performed, and a curvilinear trend was revealed. That is, the severity of the blues scores began to increase on the 2nd day postpartum and continued to increase until the 6th day postpartum, when it began to decrease. By averaging each primipara s daily maternity blues scores for the first 7 days postpartum, a mean maternity blues score for the week was calculated. The mean maternity blues scores for the week were 5.51 (SD = 4.36) for the group of mothers who were discharged early and 5.91 (SD = 3.38) for the group discharged after the customary length of stay. A t-test revealed no significant difference between the two groups mean maternity blues scores for the 1st week postpartum, so their scores on the Stein Maternity The percentage of primiparas experiencing severe maternity blues increased steadily each day, from the 1st to the 5th day postpartum. Blues Scale were combined for the remainder of the study. On the 4th day postpartum, the largest percentage, 65% (n = 31), of the total sample experienced the blues (see Figure 2). On the 7th day postpartum, the smallest percentage, 50% (n = 23), of the sample experienced the blues. The percentage of primiparas experiencing severe maternity blues increased steadily each day, from the 1st to the 5th day postpartum, at which time the peak incidence of severe blues, 35% (n = 17) of the sample, occurred. After that, on the 6th and 7th days postpartum, a decline in the percentage of primiparas experiencing severe blues was observed. Beck Depression Inventory Repeated analysis of variance on the measures used in the study did not reveal any significant differences at 1,6, and 12 weeks postpartum in the mean depression scores for the two groups of mothers. For the total sample of 49 primiparas, the mean depression scores at 1, 6, and 12 weeks after birth were 5.63, 4.97, and 4.49, respectively. Only one primipara experienced severe depression, which occurred at 1 week after delivery. Also at 1 Figure 1. Comparison of daily mean total maternity blues score during the first PosQartum week for primiparas discharged early versus primiparas discharged after customary length of stay. ---t Traditional Discharges -- W-- Early Discharges I Ot, I POSTPARTUM DAY 290 J O G N N Volume 21 Number 4

5 Maternity Blues and Postpartum Depression w t mnane=mild to Modemte 5 v e r e 5 n 0 I POSTPARTUM DAY Figure 2. Severity of maternity blues during the 1st pos@artum week for the total sample of primiparas. week postpartum, 19.6% of the total sample were mildly depressed, while none were moderately depressed. At 6 weeks after delivery, 10.2% and 5.2% of the primiparas experienced mild and moderate depression, respectively. At 12 weeks after delivery, 13.5% of the mothers were mildly depressed and 2.7% were moderately depressed. No significant differences were found at 1, 6, and 12 weeks postpartum in tbe mean depression scores for motbers who were discharged early, as compared with mothers who were discharged after the customary length of bospital stay. Depression levels at 1 week postpartum for the total sample were significantly related to depression levels at 6 weeks postpartum (r =.44, p =.005). Also, depression levels at 6 weeks postpartum correlated significantly with depression levels at 12 weeks after delivery (r =.58, p =.OOO). The mean maternity blues scores for the 1st week postpartum were significantly correlated with the Beck Depression Inventory scoresat 1 week (r=.85,p =.OOO), 6 weeks (r =.43, p =.Ol), and 12 weeks postpartum (r = 32, p =.05). Limitations The fact that the sample of mothers who participated in the study was a convenience sample limits the generalizability of the findings to similarly constituted sets of primiparas. The small sample size lowers the larger samples will be needed in future research to help ensure a better representation of women with all degrees of postpartum depression. probability of detecting significant differences between the two groups with respect to maternity blues scores and postpartum depression scores. Another factor possibly responsible for the lack of significant differences between these two groups of mothers is the mean length of time that the primiparas who were discharged early had stayed in the hospital after delivery (33 hours). If the difference in the number of hours hospitalized after delivery for the two groups had been larger, significant differences between the groups might have been revealed. Another limitation of the study is that only one mother in the sample had been seriously depressed, and only during the 1st week postpartum. Also, the mean depression scores for the total sample at 1, 6, and 12 weeks after delivery fell into the no-depression range. Larger samples will be needed in future research to help ensure that the studies include a better representation of women with all degrees of severity of postpartum depression. Discussion The lack of any significant difference exhibited between the two groups of primiparas regarding the incidence of maternity blues and postpartum depression lends support to the notion that early discharge programs are psychologically safe. The percentage of the sample that suffered from the blues during the first 7 days after delivery ranged from 50-65%. This finding is within the previously reported rates of maternity blues in the United States (Buesching et al., 1986; Yalorn et al., 1968). At 6 weeks postpartum, 15.4% of all the primiparas had experienced mild to moderate depression. This percentage is higher than the 10% rate at 6 weeks postpartum reported by Saks et al. (1985). The 16.2% of the total sample that experienced mild to moderate postpartum depression at 12 weeks after delivery is consistent with the incidence rate of 16.5% reported by O Hara et al. (1982) but lower than the 20% found to suffer from the condition by Cutrona and Troutman (1986) with their sample of mothers at 3 months after delivery. The finding that the mean maternity blues scores for the first 7 days after delivery were significantly correlated with the Beck Depression Inventory scores at 1,6, and 12 weeks postpartum lends support to ear- July/August 1992 J O G N N 291

6 C L I N I C A L S T U D I E S lier research conducted in Great Britain that had found an increased risk of postpartum depression in mothers who had experienced the blues (Paykel et al., 1980; Stein, 1980). Nursing Implications Maternity blues has been described repeatedly as trivial or fleeting. The results of the current study, however, indicated that the blues may be an important predictor of women at risk for a depressive illness later during the puerperium. Because maternity blues mainly has been considered a normal concomitant of the postpartum period, its clinical significance has not been appreciated fully, nor has the nursing profession called for any active interventions. The prevalence and severity of the blues reported in the sample of primiparas investigated, and the significant relationship of the blues to postpartum depression, should begin to alert nursing to the clinical importance of this neglected condition. The peak incidence of the most severe blues for the total sample was on the 5th day postpartum, when the mothers already had been discharged from the hospital. Thus, there is a need for postpartum programs dealing with the blues both for primiparas discharged early and for primiparas discharged after the customary length of hospital stay. Through home visits or telephone calls, nurses can focus on identifying mothers' behavior patterns with regard to the blues. Since a significant relationship was found between the blues during the 1st week after birth and depression at both 6 and 12 weeks postpartum, periodic follow-up visits during the first 6 to 12 weeks after delivery could be scheduled for those primiparas experiencing more severe blues. Early nursing interventions aimed at preventing primiparas from experiencing postpartum depression could be initiated with this high-risk group of first-time mothers. It is critical for nurses to intervene as early as possible to prevent long-term effects on children of mothers who go on to suffer severe maternal depression. Psychiatric referrals may be needed for mothers with severe postpartum depression. For the majority Of mothers with Of postpartum depression, nurses can alert these women to the existence of local postpartum depression support groups, such as the Association for Postpartum Disorders in Plantation, Florida. Support groups can help mothers afflicted with a postpartum disorder of any degree to a network in which those mothers help other mothers and to assist their families. Leathe (1987) identified three benefits of a postpartum depression support group for mothers: (a) the group confirms the reality of the condition; (b) it Tbe Prmalence and smew~ Of the blues reported in this sample of prlmiparas, and its signijicant relationsbip to postpartum depression, sbould begin to alert nursing to its clinical importance. counters their isolation and loneliness; and (c) it provides hope that postpartum depression can be overcome and that life will be normal again. If a local support group has not been formed yet, mothers can be referred to the national organization, Depression After Delivery, in Morrisville, Pennsylvania, or to Postpartum Support International, in Santa Barbara, California. Because health professionals cannot predict with accuracy which mothers are at risk for postpartum depression, Boyer (1990) warns that it is paramount that all pregnant women and their families be taught about the symptoms of postpartum emotional disorders, preventive measures, and where to find help. Sample patient education materials about postpartum depression have been prepared by Boyer (1990) and can be shared with pregnant women and their families. Future research might investigate (a) the relationship of maternity blues or postpartum depression to other life events, such as marital problems, and (b) whether any of the symptoms of the blues are more predictive of postpartum depression than others. Although the two groups of primiparas examined in this study did not differ significantly with regard to the incidence and characteristics of maternity blues, further investigation may be warranted to follow the trend of a lower incidence of maternity blues for the group discharged early. Qualitative research on maternity blues and postpartum depression also is needed to gain valuable insight about the world experienced by the mothers suffering from these disorders. Acknowledgment This study was supported by the Harriet and Cora F. Shoecraft Fund, awarded by the Catherine McAuley Health Center in Ann Arbor, Michigan. References Atkinson, A., & Rickel, A. (1984). Postpartum depression in primiparous parents. Journal of Abnormal Psychology, 93, Avery, M., Fournier, L., Jones, P., & Sipovic, C. (1982). An early postpartum hospital discharge program: Imple- 292 JOG" Volume 21 Number 4

7 Maternity Blues and Postpartum Depression mentation and evaluation. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 11, Beck, A. (1978). Beck depression invento y. Philadelphia: Center for Cognitive Therapy. Beck, A., Ward, C., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiaty, 4, Boyer, D. (1990). Prediction of postpartum depression. NAACOG s Clinical Issues in Perinatal and Women s Health Nursing, 1, Bridge, L., Little, B., Hayworth, J., Dewhurst, J., & Priest, R. (1985). Psychometric ante-natal predictors of post-natal depressed mood. Journal of Psychosomatic Research, 29, Buesching, D., Glasser, M., & Frate, D. (1986). Progression of depression in the prenatal and postpartum periods. Women and Health, 11, Cogill, S., Caplan, H., Alexandra, H., Robson, K., & Kumar, R. (1986). Impact of maternal postnatal depression on cognitive development of young children. British MedicalJourna1, 292, Cox, J., Connor, Y., & Kendell, R. (1982). Prospective study of the psychiatric disorders of childbirth. British Journal ofpsychiaty, 140, Cutrona, C., & Troutman, B. (1986). Social support, infant temperament, and parenting self-efficacy: A mediational model of postpartum depression. Child Development, 57, Handley, S., Dunn, T., Waldron, G., & Baker, J. (1980). Tryptophan cortisol and puerperal mood. British Journal of Psychiatry, 136, 498. Kendell, R., McGuire, R., Connor, Y., & Cox, J. (1981). Mood changes in first 3 weeks after childbirth. Journal of Affective Disorders, 3, Leathe, M. (1987). Postpartum depression. Mothering, Lemmer, S. (1986). Early discharge: Outcomes of primiparas and their infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 17, Little, B., Hayworth, J., Benson, P., Bridge, L., Dewhurst, J., & Priest, R. (1982). Psychophysiological ante-natal predictors of postnatal depressed mood. Journal of Psychosomatic Research, 26, Mehl, L., Peterson, G., Sokolowsky, W., &Whitt, M. (1976). Outcomes of early discharge after normal birth. Birth and Family Journal, 3, O Hara, M., Neunaber, D., & Zekoski, E. (1984). Prospective study of postpartum depression: Prevalence, course, and predictive factors. Journal of Abnormal Psychology, 93, O Hara, M., Rehm, L., &Campbell, S. (1982). Predicting depressive symptomatology: Cognitive-behavioral models and postpartum depression. Journal of Abnormal Psychology, 91, Paykel, E., Emms, E., Fletcher, J., & Rassaby, E. (1980). Life events and social support in puerperal depression. British Journal of Psychiaty, 136, Reynolds, W., d Gould, J. (1981). A psychometric investigation of the standard and short form Beck Depression In- ventory. Journal of Consulting and Clinical Psychology, 49, Richman, N. (1981). A community survey of characteristics of one to two year olds with sleep disruptions. Journal of the American Academy of Child Psychiatry, 20, Saks, B., Frank, J., Lowe, T., Berman, W., Naftolin, F., Phil, D., & Cohen, D. (1985). Depressed mood during pregnancy and puerperium: Clinical recognition and implications for clinical practice. American Journal of Psychiaty, 142, Sameroff, J., Siefer, R., & Zax, M. (1982). Earlydevelopment of children at risk for emotional disorders. Monographs of the Society for Research on Child Development, 47, Spitzer, R., Endicott, J., & Robins, E. (1978). Research diagnostic criteria: Rationale and reliability. Archives of General Psychiatry, 36, Stein, G. (1980). The pattern of mental change and body weight change in the first postpartum week. Journal of Psychosomatic Research, 24, Strober, M., Green, J., &Z Carlson, G. (1981). Utility of the Beck Depression Inventory with psychiatrically hospitalized adolescents. Journal of Consulting and ClinicalPsychology, 49, Weissman, M., Prusoff, B., Gammon, G., Merikangas, K., Leckman, F., & Kidd, K. (1984). Psychopathology in the children (ages 6-18) of depressed and normal parents. Journal of the American Academy of Child Psychiaty, 23, Whiffen, V. (1988). Vulnerability to postpartum depression: A prospective multivariate study. Journal of Abnormal Psychology, 97, Whiffen, V., & Gotlib, I. (1989). Infants of postpartum depressed mothers: Temperament and cognitive status. Journal of Abnormal Psychology, 98, Yalom, I., Lunde, D., Moos, R., & Hamburg, D. (1968). Postpartum blues syndrome. Archives of General Psychiaty, 18, Yanover, M., Jones, D., &Miller, M. (1976). Perinatal care of low risk mothers and infants-early discharge with home care. New EnglandJournal ofmedicine, 294, Zuravin, S. (1989). Severity of maternal depression and three types of mother-to-child aggression. American Journal of Orthopsychiaty, 59, Address for correspondence: Cheryl Tatano Beck, DNSc, CNM, Florida Atlantic University, College of Nursing, PO Box 3091, Boca Raton, FL Cheryl Tatano Beck is an associate professor at Florida Atlantic University in Boca Raton. Dr. Beck is a member of NAACOG. Margaret A. Reynolds is the director of clinical research at Catherine McAuley Health Center in Ann Arbor, Michtgan. Patricia Rutowski is the director of maternal-child nursing at Catherine McAuley Health Center. Ms. Rutowski is a member of NAACOG. July/Augzlst 1992 J O G N N 293