Postpartum Depression in a Military Sample

MILITARY MEDICINE, 173, 11:1085, 2008 Postpartum Depression in a Military Sample Capt Kathryn Kanzler Appolonio, USAF BSC*; Randy Fingerhut, PhD ABSTRACT Postpartum depression (PPD) affects nearly 1 in 8 mothers and has many negative implications. Studies show particular risk factors are linked with PPD. There are nearly 200,000 women serving in the U.S. Armed Forces, but little is known regarding PPD and active duty (AD) mothers. This study examined rates and risk factors for AD mothers and found that 19.5% were positive for PPD symptoms. Ten significant psychosocial factors were associated with PPD, including low self-esteem, prenatal anxiety, prenatal depression, history of previous depression, social support, poor marital satisfaction, life stress, child care stress, difficult infant temperament, and maternity blues. This study has implications for prevention, identification, and treatment of AD military women with PPD. INTRODUCTION Postpartum depression (PPD) is considered a type of major depressive disorder occurring within the first 4 weeks after delivery. 1 A meta-analysis of 59 studies reported an average rate of PPD of 13%, 2 although some studies reported even higher rates. 3 PPD has a negative impact on parenting ability 4,5 and child development. 6,7 Spouses of women with PPD have reported increased stress, 8 may suffer psychological problems, and experience less marital satisfaction. 9 There are many factors contributing to the development of PPD. Meta-analyses have identified 13 psychosocial risk factors for PPD. 10,11 Ten of these variables, including prenatal depression, self-esteem, child care stress, prenatal anxiety, life stress, social support, marital relationship, history of depression, infant temperament, and maternity blues, had moderate effect sizes. The remaining three, that is, marital status, socioeconomic status, and unwanted/unplanned pregnancy, had small but significant effect sizes. Transitioning into motherhood is a difficult task, and this role shift may be particularly challenging for employed women. It is estimated that 50% of women with infants 1 year of age are employed. 12 Employed women may have better mental health outcomes when they take longer maternity leaves and work fewer hours per week. 13 Returning to work has been found to contribute to improved mood in the postpartum period. 14 des Rivieres-Pigeion et al. 15 determined that social support could mediate the relationship between work status and depression, evidenced by the more isolated position of a homemaker. Professional identity may also be a source of protection against PPD, 16 and employment may *Clinical Health Psychology, Wilford Hall Medical Center, San Antonio, TX 78236. Department of Psychology, Doctoral Program in Clinical Psychology, La Salle University, Philadelphia, PA 19143. Some of the data from this article were presented at the 40th Annual Association for Behavioral and Cognitive Therapy Conference, November 16 19, 2006, Chicago, IL. This manuscript was received for review in April 2008. The revised manuscript was accepted for publication in August 2008. Reprint & Copyright by Association of Military Surgeons of U.S., 2008. provide opportunities for more social support, positive feedback, fiscal autonomy, and stress management. 17 Nearly 200,000 women are active duty (AD) members of the U.S. Armed Forces. 18 This population has many protective factors, compared with the civilian working population. One study indicated that nearly 100% of military mothers attended check-ups during pregnancy. 19 Additionally, military mothers have access to special health care services, such as diet, alcohol, and smoking counseling and infant care, exercise, and breastfeeding classes, at no cost. 19 Although there are benefits to AD status, military mothers also experience unique stressors, compared with civilian mothers. A study noted that pregnant dependent spouses and AD military women reported low levels of stress but the AD women worked longer into their pregnancies and reported less support. 20 They also reported more work hours per week and more weeks spent working throughout their pregnancies. Military mothers may feel especially torn between the demands of family and career. 21 Additionally, struggling AD members may be hesitant to reveal emotional concerns because of fear of occupational repercussions. 22,23 The difficulties inherent in disclosing mental health information may be considered a risk factor for this population, because depressive symptoms may be left unidentified and untreated. Compared with the magnitude of research on PPD and civilian women, studies focusing on military women are lacking. Research found a rate of PPD among 26 AD women of 19%. 24 Another study reported that 11% of 109 AD mothers were positive for PPD. 25 New military mothers have reported increased parenting and occupational stress. 26 Additional findings indicate that parental stress among military mothers may increase family-work conflict, which may then increase depression and decrease functioning. 21 When military mothers were invested and involved in each of their roles (occupational, marital, and parental), however, distress was reduced, lessening depressive symptoms. There have been positive findings related to civilian employment and decreased PPD symptoms, 15,16 but military mothers do not necessarily have the protective characteristics correlated with employment. For example, enlisted military 1085

mothers in particular may have only high school diplomas, be single, be younger, have less support, and have more unwanted pregnancies. 27 Alternatively, some military mothers may be less susceptible to depression because of employment-related social support and well-timed pregnancies. At this time, the literature does not appear to thoroughly address frequency or contributing factors for PPD among AD military women. This exploratory study begins to bridge the gap in the literature by examining AD military mothers and the effects of their unique employment situation on postpartum mental health. The following questions are examined. (1) What is the prevalence rate of PPD in an AD military sample? (2) What psychosocial and demographic risk factors are associated with PPD symptoms for military mothers? (3) Are these risk factors different from those identified in studies of civilian mothers? METHODS Participants All AD military women, including activated reservists and activated National Guard members, who gave birth at Wilford Hall Medical Center (WHMC) (Lackland Air Force Base, San Antonio, Texas) were invited to participate in the study. The initial exclusion criterion was that participants complete the measures within the first 6 months after delivery. Additionally, letters were not sent to mothers who had poor delivery outcomes (low Agpar scores, fetal anomalies, or deliveries before 28 weeks). This step was taken to prevent study invitations being inadvertently sent to women who might have lost their babies. Measures The participants completed three measures, namely, the Edinburgh Postnatal Depression Scale (EPDS), 28 a modified Postpartum Depression Predictors Inventory-Revised (PDPI- R) 29 (Table I), and a demographic questionnaire (Table II). The EPDS was developed by Cox et al. 28 to aid primary care providers in detecting PPD. Its 10 items are related to PPD symptoms and requests patients to respond based on the past week. A score of 12 or 13 is a recommended cutoff value to indicate the presence of depression. A conservative cutoff value of 12 was used in this study, to avoid false-positive results and to achieve consistency with procedures in similar studies (e.g., the study by O Boyle et al. 24 ). The EPDS has solid reliability, 30 as well as validity sensitivity and specificity. 31 The PDPI-R was developed from meta-analytic findings 10 as a clinician-administered interview. 32 It was revised in 2002 29 on the basis of an updated meta-analysis 11 that identified 13 factors that place women at risk for PPD. Each of the statistically significant factors is represented in the original measure, that is, marital status, self-esteem, prenatal depression, prenatal anxiety, unplanned/unwanted pregnancy, history of previous depression, social support, marital satisfaction, life stress, child care stress, infant temperament, and TABLE I. Modified PDPI-R Please choose one answer that best describes your situation. 1. What is your marital status? Single Married/cohabitating Divorced Separated Widowed Partnered 2. How would you describe your income level? Low Middle High 3. How have you viewed yourself in the past week? I believe I am worthwhile. I believe I have some good and bad qualities. I have been having a lot of doubts about myself. I believe I am utterly worthless. 4. Did you experience depression during your pregnancy? I did not experience any depression. I experienced mild depression. I experienced moderate depression. I experienced severe depression. 5. Did you experience anxiety during your pregnancy? I did not experience any anxiety. I experienced mild anxiety. I experienced moderate anxiety. I experienced severe anxiety. 6. How would you describe your pregnancy? It was a planned pregnancy. It was unplanned, but I wanted to have the baby. It was unplanned, and I was unsure about whether or not to have the baby. I did not want to have this baby. 7. Before this pregnancy, have you ever been depressed? No, never. Yes, I experienced one episode of depression. Yes, I have experienced more than one episode of depression. I have been depressed for as long as I can remember. 8. In general, how much support do you currently receive from your partner, friends, and family? I receive enough social support. I receive some social support, but I wish it were more. I receive a minimal amount of social support. I receive no support whatsoever. 9. How satisfied are you currently with your marriage (or living arrangement)? Please answer this question only if you are in a relationship. I am completely satisfied with my marriage/living arrangement. I am somewhat satisfied with my marriage/living arrangement. I am not very satisfied with my marriage/living arrangement. I am completely unsatisfied with my marriage/living arrangement. 10. Apart from having a new child, how much stress are you currently experiencing in your life (examples of stressful life events include but are not limited to financial difficulties, death or illness in the family, moving, unemployment, or job change)? No more stress than usual. A little bit more stress than usual. Much more stress than usual. The most stress I have ever had. (Continued) maternity blues. The first 10 factors may be assessed both during and after pregnancy, whereas the last three are appropriate only in the postpartum period. Each question corresponds 1086

TABLE I. (Continued) TABLE II. Background Questionnaire 11. Does your infant have any particular difficulties with his/her health, sleeping, or eating? My infant is not having any particular difficulties with his/her health, sleeping, or eating. My infant is having mild difficulties with his/her health, sleeping, or eating. My infant is having moderate difficulties with his/her health, sleeping, or eating. My infant is having severe difficulties with his/her health, sleeping, or eating. 12. How would you describe your infant s temperament? My infant is not particularly irritable or fussy. My infant is somewhat irritable and fussy. My infant is moderately irritable and fussy. My infant is extremely irritable and fussy. 13. How would you describe your mood during the first week after your delivery? I did not have any mood swings or tearfulness. I had mild mood swings and tearfulness. I had moderate mood swings and tearfulness. I had severe mood swings and tearfulness. to a factor that has been found to be a statistically significant contributor to PPD. 10,11 Although a recent study examined total score and cutoff value options, 33 the PDPI-R was used in the present investigation to help identify exactly which risk factors may contribute to PPD in a military sample. The PDPI-R was designed for use as a clinical interview, but it has been used in a self-report format with positive results. 34 We received permission from the developer (C.T. Beck, personal communication) to further modify the instrument into a selfreport measure that is more amenable to statistical analyses. The modification was loyal to the original measure s 13 questions but altered the format from open-ended questions to Likert scale response options. A 22-item, multiple-choice, background questionnaire was created to identify potential characteristics associated with PPD symptoms. The items focused on military-specific and demographic variables, such as deployment status, branch of service, and rank. 1. What is your age? 2. What is your ethnic background? African American, non-hispanic Caucasian, non-hispanic Hispanic Asian Native American/Pacific Islander Other 3. What is the highest level of education you have completed? High school or GED Some college Associate s degree Bachelor s degree Postgraduate degree Other 4. How many years have you been in the armed services? 5. With what branch of the U.S. military do you currently serve? Air Force Army Navy Marine Corps National Guard What branch? Reserves Which branch? 6. What is your military rank? 7. What is your government pay grade? 8. What is your military job code? 9. Where is your current military station? 10. Please choose the most appropriate response describing your status. I do not believe I will be deployed. I believe I will be deployed somewhere outside of a war zone. I believe I will be deployed to a war zone. 11. Do you currently live in military housing? 12. Will you be making a permanent change of station within the next 6 months? 13. How many children do you have? 14. What is your newborn baby s age? 15. Approximately, how many hours do you sleep per night? 16. Do you breastfeed your baby? 17. How long is your maternity leave? 18. Did you have any pregnancy complications? 19. If yes, please explain. 20. Have you ever been treated for postpartum depression? 21. Please choose the most appropriate response describing your spouse/partner. I do not have a spouse/partner. My spouse/partner is not in the military. My spouse/partner is in the military. 22. If you do have a spouse who is in the military, please choose the most appropriate response describing your spouse/partner s status. I do not believe my spouse/partner will be deployed within the next 6 months. I believe my spouse/partner may be deployed within the next 6 months. My spouse/partner is currently deployed. Procedure Once each month, the WHMC Office of Clinical Investigations received, from the obstetrics/gynecology department chief, the names of all AD women who had given birth. Each new mother was sent an invitation letter through the Office of Clinical Investigations, informing her of the study. Informative posters and small printed materials were also displayed in the obstetrics/gynecology and pediatric department waiting rooms. The letter and advertisements listed an Internet address, where the participants electronically gave informed consent and completed the measures. There was an option at the close of the survey to give an e-mail address if the participants were interested in receiving an online-redeemable, $5 gift card to a well-known baby-needs store. The participants were aware that e-mail addresses were not linked to the data and would have no purpose other than communication of payment. Continuation to the debriefing page occurred for every participant, with or without an e-mail address. The debriefing page presented information on contacting the WHMC mental health clinic, a support hotline (Department of Defense Military OneSource), and a special military resource number (Texas 211). Also presented were multiple methods for contacting the researchers. 1087

Care was taken to ensure that, in this online study, proper informed consent was given, anonymity was provided, and effective debriefing was presented, as outlined by Kraut et al. 35 This study was approved by the WHMC institutional review board, and Health Insurance Portability and Accountability Act guidelines were followed. At no time did the authors have access to protected health information, because the investigators and the Office of Clinical Investigations actively prevented disclosure of the participants protected health information. RESULTS A total of 526 women were sent letters of invitation, and an unknown number viewed the study posters. Ninety-two responded and participated in the study. Four participants did not complete the measures, and one mother participated past the 6-month time period; these five women were excluded from analysis. A total of 87 participants were included in data analysis. Participants completed measures an average of 11.7 weeks after delivery. As noted in Table III, most participants were Caucasian and serving in the U.S. Air Force. The mean age of the participants was 30 years, with an average of 1.7 children; 54% of sample was multiparous. Participants had been in the military for an average of 8 years; 68% were first-term service members (defined as serving 4 years). Most (63%) were enlisted personnel, rather than officers. Married or partnered mothers composed 84% of the sample and, of those couples, 55% were dual-military. More than one-third (39%) of the participants reported medical complications of some type. Mothers had an average of 46 days of maternity leave, consistent with the typical 42-day maternity leave allotted to all military mothers. A score of 12 on the EPDS (a cutoff value indicating the presence of significant PPD symptoms) was found for 19.5% of the participants,. The scores ranged from 0 to 22, with an average score of 6.4 (SD, 5.4). Bivariate nonparametric correlations were conducted to determine relationships between PDPI-R variables and EPDS TABLE III. Demographic Data (N 87) Variable No. (%) Ethnicity Caucasian 54 (62.1) African origin 12 (14) Hispanic 14 (16.1) Asian 3 (3.4) Native American/Pacific Islander 2 (2.3) Other 2 (2.3) Branch of service U.S. Air Force 61 (70) Army 20 (23) Navy 3 (3.4) National Guard and Reserve 3 (3.4) Percentages may not equal 100 because of rounding. scores. Because these items are already established as being correlated with PPD in the general population, 10,11 the goal of this exploratory study was to determine whether these factors were correlated with PPD in a military sample. Because testing a model of factors was not justified in this exploratory study, multivariate regression correlations were not conducted. Twelve items on the modified PDPI-R are ordinal data, whereas one item (marital status) is nominal. Therefore, Spearman s analyses (two-tailed) were conducted with 12 of the 13 factors on the PDPI-R. Analyses indicated significant positive correlations between 10 of these items and scores on the EPDS (Table IV). Marital status was analyzed by using Pearson s 2 tests. The analysis showed that one cell had an expected count of 5; therefore, an exact significance test was selected. There was no relationship between marital status and EPDS scores ( 2 0.038, df 1, exact p 1.000). Pearson s 2 analyses were also conducted for PPD symptoms and nominal military-specific variables. EPDS scores were coded dichotomously, dividing patients with scores of 12 and 12. As displayed in Table V, analyses indicated no relationship between PPD symptoms and military factors. DISCUSSION This study found a rate of PPD in an AD military sample of nearly 20%. This value is consistent with findings in another military sample. 24 Although the rate it is elevated in comparison with averages in the civilian population, it is within the range reported in various other studies. 3 It is unclear what contributing factors might be responsible for an increased rate of PPD symptoms in this sample. Some studies have suggested that neither employment status 36 nor occupation type 2 is an important variable related to PPD. This sample was drawn from patients at a large hospital known for its treatment of complicated pregnancies; it is interesting to highlight that nearly 40% of this sample endorsed complications, a factor noted for its contribution to PPD. 37 The elevated rate may also reflect a unique struggle AD mothers face; one TABLE IV. Correlations Between PDPI-R Variables and EPDS Scores Factor Spearman s Low self-esteem 0.645 a Prenatal anxiety 0.493 a Poor marital/partner satisfaction b 0.449 a Maternity blues 0.453 a Life stress 0.445 a Prenatal depression 0.401 a Difficult infant temperament 0.374 a Poor social support 0.368 a History of previous depression 0.361 a Childcare stress 0.258 c Income level 0.111 Unexpected pregnancy 0.008 a p 0.01 (two-tailed). b N 66. c p 0.05 (two-tailed). 1088

TABLE V. Relationship between Military Variables and EPDS Scores Variable 2 Officer/enlisted rank 0.020 Deployment status 0.737 Spouse/partner military status 0.196 On/off-base housing a 0.395 Permanent change of station status a 0.104 Military spouse deployment status a 0.073 a The analyses showed that at least one cell had an expected count of 5; therefore, an exact significance test was selected for Pearson s 2. study found that 51% of military women indicated a belief that there is no ideal time to have both children and a military career. 27 Other investigators reported that 25% of women who chose to leave the military identified work-family conflict as a reason for separation. 38 It is possible that our sample subjects struggled with such concerns, which were not directly assessed in this study. Ten psychosocial factors were associated with PPD, including low self-esteem, prenatal anxiety, prenatal depression, history of previous depression, social support, poor marital satisfaction, life stress, child care stress, difficult infant temperament, and maternity blues. Three factors were not, including income level, marital status, and unplanned pregnancy, which is consistent with the meta-analysis by Beck, 11 in which the same factors had only small effect sizes, whereas the other 10 had moderate effect sizes. Particularly interesting is the lack of association between PPD and military-specific factors. Women who were in a dual-military relationship were not at higher risk for PPD. Additionally, women who were dealing with an impending deployment or whose spouses were deployed were not more likely to report depressive symptoms. An upcoming military move, rank, and base housing were also unrelated to symptoms of PPD. One possibility is that differences were not detected because of the study being underpowered. Although none of the analyses detected a trend in the data, it is possible that a larger sample size might contribute to elucidation of potential relationships between military-specific variables and PPD. An alternative is that these findings are reasonable, because women who choose to join the armed services may find the challenges and culture congruent with their lifestyle. Additionally, if pregnant enlisted members find the military environment incompatible with motherhood, they may request discharge. 39 As previously stated, health care and supportive programs for military families during and after pregnancy are comprehensive and may actually serve as protective factors against PPD. However, military-specific environmental features that were not assessed could actually be affecting the 10 identified risk factors. Perhaps life stress could be accounted for by occupational stress, marital satisfaction might be affected by military lifestyle, or child care stress might be affected by long work hours. This study has generated information that may help identify military mothers who have or are at risk for PPD. Although some military hospitals, such as this data collection site, assess and actively treat women with PPD, these results indicate it is imperative for other military bases to continue using, or consider adopting, such a protocol. It is interesting to note that all of the women in this study had already been given the EPDS during their obstetrics/gynecology visits and were automatically referred for treatment if they scored 12. This sample s rate of PPD was nearly 1 in 5, despite the fact that each woman had already been screened for PPD. Other military health care facilities without this procedure could have particularly high rates of undiagnosed and untreated PPD. Understanding factors that contribute to PPD in AD women can also lead to more effective prevention and intervention efforts. Although some military members are hesitant to disclose the presence of emotional distress because of stigma or fear of occupational consequences, 22,23 knowing the risk factors can alert health providers to further assess the presence of PPD when a mother presents with significant factors. Identification and treatment of PPD could improve the quality of life and the quality of health care for military service members. Reduced costs to the government resulting from lost time and poor work quality may also be a positive result. This study s method is an example of how technology can be used to gather data from special populations. Online data were collected while the primary investigator was residing thousands of miles away from the collection site, but the investigators were still able to safeguard the data until conclusion of the study (at which time it will be destroyed). Additionally, the completely anonymous nature of the method provided the opportunity for military women to disclose more information than they might be comfortable doing with their health care providers. 22,23 This research displays a confidential methodological standard for gathering and safeguarding sensitive information. There are several limitations in this work, largely attributable to the exploratory nature of the study. The psychosocial risk factors were measured only through single-question Likert scale items, and the presence or absence of risk factors was not fully assess. It was not feasible to investigate these factors with individual measures because of the time required and expense, as well as difficulty recruiting mothers with spare hours for study participation. Additionally, the PDPI-R was originally developed as a screening tool for identifying women at risk 29 and was appropriate for rapid identification of risk factors in this sample. Furthermore, it is important to consider the correlational nature of this study, noting that causation cannot be inferred. Although risk factors are discussed, it is not clear whether these factors are present before PPD or arise as a result of the disorder. For example, poor marital satisfaction could occur after onset of PPD or contribute to its development. It is also important to note that our sample may not accurately reflect the military population as a whole, because 1089

a single site was the source of all data collected and the sample size was relatively small. This sample also reflected over-representation of military officers (nearly 40%), compared with the female U.S. Air Force population of 80% enlisted personnel and 20% officers. 40 As stated previously, rank did not statistically significantly distinguish depressed from nondepressed participants. More than one-half of the married/partnered women were in dual-military relationships. However, there were also no detectable differences related to spouse status. Approximately one-third of the sample subjects were serving their first term in the military, which also indicates greater participation of more seasoned military members than might be expected. It is also interesting to note that more than one-half of the participants were multiparous; some researchers have found that parity is important, because multiparous women may be more vulnerable to PPD. 41 Although many women with medical complications participated, our letter-based advertising did exclude women with poor outcomes, which also could have biased our results. Finally, these participants were self-selected and might have chosen to respond to advertisements because of personal concerns related to the study topic. Our response rate was 17.5%. It is not known whether mothers solicited in person would have been more participative than those solicited by letter. However, the burden of advertising/soliciting was greatly reduced by mailing a letter, rather than requesting military medical staff members to discuss the study with women at the time of their delivery/ postpartum follow-up visits. Additionally, the primary investigator was residing thousands of miles away from the collection site. The completely anonymous nature of the study was also viewed as a benefit of letter-based recruitment. Future studies should focus on multiple sites, larger sample sizes, and additional methods for assessing risk and protective factors. Expanded military-specific questions would better examine the effects of the military environment and wartime status on mothers mental health. Work-family conflict should be considered in this population as well. It would helpful to identify any differences related to branch of service, as well as the unique circumstances that activated reservist and National Guard members face (e.g., distance from units, varying military-based supportive services, and different deployment tempos/situations). Length of time in service, parity, and adverse outcomes/pregnancy complications are also worthwhile factors to investigate. A prospective study would help clarify the directionality of correlated factors; consideration of current treatment status, such as psychotropic medication or participation in psychotherapy, would also be helpful. An examination of anonymously reported EPDS scores and those endorsed during obstetric visits would also be useful; unfortunately such analyses were not feasible in this study. In conclusion, the reported findings of our study may allow for more targeted prevention and treatment of PPD in a military setting. There are identification and treatment protocols at certain military hospitals, such as WHMC. 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