Abstract
Background:
In women with major depressive disorder (MDD), maternal role functioning is negatively impacted but has been shown to improve with treatment; however, most investigations have not included a control group or studied women longitudinally. We hypothesized that women with MDD who responded to serotonin selective reuptake inhibitors (SSRIs) would have overall functioning and maternal role functioning scores similar to that of the control group and superior to women with MDD (either untreated or nonresponsive to SSRIs).
Methods:
This prospective, longitudinal observational study (n = 215) included postpartum assessments at 2 1/2 weeks, 3 months, 6 months, and 12 months. Postpartum women were categorized into four mutually exclusive exposure groups by depression and medication status: (1) Control group (no SSRI, no MDD; (2) Responder (SSRI, no MDD); (3) Untreated (MDD, no SSRI); and (4) Nonresponder (Both MDD and SSRI). Outcome variables include a measure of overall functioning (Global Assessment Scale, GAS) and three measures of maternal role functioning (Maternal Self Efficacy, ICS; Gratification in Maternal Role, GRAT; and overall maternal role functioning, IFSAC).
Results:
The study hypothesis was supported. Responders had scores related to overall functioning and maternal role functioning that were similar to the control group and superior to nonresponders and untreated women with MDD, as measured by the GAS and the GRAT.
Conclusion:
Postpartum depression treatment optimally targets both symptom improvement and maternal functional recovery. The GRAT is a simple, self-administered instrument that can be used with a depression measure to assess maternal role functioning.
Keywords: depression, treatment, postpartum
INTRODUCTION
In the United States, depression is a common disorder that is under-recognized and infrequently treated[1] particularly in childbearing women.[2] Depression is associated with diminished functioning at work,[3] early retirement,[4] impaired interpersonal relationships,[5] less recreation,[6] decreased overall life satisfaction,[6] exposure to interpersonal violence,[7] comorbid disease,[8] and lower quality of health-care services received.[9,10] Antidepressants, such as Serotonin Selective Reuptake Inhibitors (SSRIs), are effective in improving quality of life and functioning in successfully treated individuals,[11,12] but discontinuation of antidepressant therapy is widespread,[13] and only 22% remit and 47% respond to an initial course of antidepressant drug treatment.[14]
Depression is common in women throughout the lifespan, including during and after pregnancy. With a period prevalence of 21.9% the year following birth,[15] depression is a frequent complication of childbearing. Depression adversely impacts overall functioning[16] and maternal role functioning[17] by altering the woman’s sense of self-efficacy[18,19] and gratification in the role of mother.[20–22] Since maternal role functioning is critical to supporting a child’s well being and development, depression treatment goals include both remission of depressive symptoms and return of the woman to her desired level of functioning in all life roles.[23,24] Antidepressant treatment improves childbearing women’s symptoms and functioning.[25] However, most studies, including our own,[26,27] have been cross-sectional with data collected in the early postpartum period. Many mothers become confident and fully functional in the maternal role across the first year postbirth;[28] therefore, investigation of the impact of antidepressant treatment on new mothers is ideally longitudinal in nature. Longitudinal data will inform treatment decision making by women in collaboration with their health-care providers.
We conducted a prospective, observational study of women over the first year after birth. We hypothesized that women with major depressive disorder (MDD) who responded to SSRIs would have overall and maternal role functioning that approximated that of the control group and superior to women with MDD, either untreated or nonresponsive to SSRIs.
MATERIALS AND METHODS
The study was a prospective observational design with maternal and infant assessments at 2 1/2 weeks, 3 months, 6 months, and 12 months postpartum. This study was a component of a larger investigation of the impact of exposures to MDD or SSRI during pregnancy on neonatal and infant outcomes.[29]
STUDY SUBJECTS
Pregnant women at the age of 15–44 years were recruited in Pittsburgh, PA (n = 215; 04/23/03–07/11/07). Women were enrolled before week 20 of gestation. Data related to pregnancy outcomes are described elsewhere.[29] Recruitment was by self- and physician referral, advertising, and screening in the obstetrical ultrasound suite. Approval was obtained from the University of Pittsburgh Institutional Review Board. All women provided written informed consent.
At each postpartum assessment point, four nonoverlapping groups of patterns of SSRI and MDD exposure were created:
Control (no SSRI, no MDD) (N = 144): no exposure to SSRI (or any antidepressant) or MDD.
Responder (SSRI, no MDD) (N = 48): SSRI treatment, no MDD. This group of women treated with SSRIs no longer had symptoms that fit criteria for MDD, and were considered responders.
Untreated (MDD, no SSRI) (N = 12): The presence of MDD throughout 12 months postpartum without SSRI treatment.
Nonresponder (Both MDD and SSRI) (N = 11): The presence of both MDD and SSRI treatment, which did not result in resolution of the MDD, throughout 12 months postpartum.
Postpartum women who received SSRI were treated by a referring physician in the community. Our study psychiatrists (DKS, KLW) provided consultation about MDD management to women with MDD or SSRI exposure and a summary was sent both to the woman and to her physician(s) with her consent. Enrollment did not depend on acceptance of recommendations or choice of treatment, and women were free to seek psychotherapy. No treatment was prescribed by the study team.
Exposures.
The sample was carefully evaluated with respect to exposures. SSRI exposure was documented by charting the subjects’ drug doses across 12 months postpartum. As we observed that nearly 15% of childbearing women in a randomized clinical trial had negligible serum drug levels,[30] we confirmed SSRI compliance with serial serum levels at each time period. Women with active substance use disorder (identified by self-report or urine drug screen), gestational exposure to benzodiazepines, or prescription drugs in the FDA-defined category of D or X were excluded from the original study. Exposures to prescribed drugs, over the counter medications, environmental agents, alcohol, or smoking were recorded at each assessment.
The diagnosis of MDD was made according to the Structured Clinical Interview for DSM-IV (SCID). The Longitudinal Interval Follow-Up Evaluation (LIFE), a semistructured interview for collection of detailed psychopathologic data for an interval period, was administered at each assessment point after the SCID. The ratings provide a separate, concurrent record of the course of each disorder initially diagnosed or developing during the follow-up interval.[31] The timeline technique[32] was also used to chart MDD course by month across postpartum period. Women with psychosis or bipolar disorder, multiple gestations, or chronic diseases (such as insulin-dependent diabetes) were excluded.
Outcomes.
Descriptive data for the sample included demographics. The overall functional measure was the Global Assessment Scale (GAS),[33] a scale rated as a single score on a continuum (0–100) from psychiatric illness to health.
The outcome measures for maternal role functioning were maternal self-efficacy,[34] gratification in the maternal role,[35] and overall maternal role functioning.[36]
Maternal self-efficacy is a woman’s belief that she can function competently in the maternal role, which contributes to adaptation to the maternal role. The Infant Care Scale (ICS) was used to measure self-efficacy. The ICS is a 52-item instrument that measures perceptions of efficacy in performing tasks in the areas of infant health, diet, and safety. Lower scores indicate higher self-efficacy. Gratification in the maternal role, rewards, and satisfactions associated with mothering was measured by the 14-item Gratification in the Maternal Role scale (GRAT). Overall maternal role functioning was measured by the Inventory of Functional Status After Childbirth Scale (IFSAC) which consists of 36 questions and subscales that focus on infant care responsibilities, household activities, social and community activities, self-care activities, and occupational activities. All three scales have been found to be decreased in women with postpartum depression in samples of Caucasian and African American adult women and in adolescent mothers.[16,21,37]
DATA ANALYSIS
Descriptive statistics were estimated for continuous measures using means and SDs, frequencies, and proportions for categorical measures. Associations between sample characteristics and membership in one of the four groups (controls, responders, untreated, and nonresponders) were tested with ANOVA when the measures were normally distributed, with the Kruskal–Wallis nonparametric test when non-normally distributed, and with chi-square tests for categorical measures. If expected, cell frequencies were small enough to violate test assumptions, Fisher’s exact tests were performed. All pairwise comparisons employed a Bonferroni correction (significance = P<.05/6).
Change in functioning during the first year postpartum was modeled using a repeated measures generalized mixed linear procedure. Each model included a random intercept in addition to fixed effects for group membership and race. An unstructured covariance matrix was assumed to allow for varying intercorrelations across the repeated measures. Adjusted least-squares means were estimated and pairwise comparisons were made using the Tukey–Kramer adjustment. The function measures were non-normally distributed and therefore transformed to meet the assumptions of the models. All analyses were conducted with SAS version 9.2.
RESULTS
SUBJECTS
On average, the sample (n = 215) was 30.4 years of age (SD = 5.7), married (75.8%), multiparous, Caucasian (79.5%), employed/attending school (66.8%), and with a college degree (40.7%) or graduate training (24.3%) (Table 1). Comparison of the characteristics of the four exposure groups revealed race was the only post hoc comparison that was significantly different P<.05/6 = .0083. The MDD, no SSRI (untreated) group had more African American women than the No MDD, SSRI (responder) group, which was almost exclusively Caucasian; and the No MDD, SSRI (responder) group was composed of more Caucasian women that the No MDD, No SSRI (control) group. These observations are consistent with other data that suggest that Caucasian women are more likely to be treated with antidepressant medication.[38,39] The number of women included in the analytic models was fewer than 215 because MDD and SSRI status sometimes changed across time points and attrition occurred in this observational study.
TABLE 1.
Demographic measures by MDD and SSRI status
| MDD | No MDD | Analyses | |||||
|---|---|---|---|---|---|---|---|
| Measure | All (N = 5215) |
SSRI (N = 11) |
No SSRI (N = 12) |
SSRI (N = 48) |
No SSRI (N = 144) |
Test statistic | P |
| Age | 30.4±5.7 | 34.4±5.4 | 28.1±7.9 | 31.8±4.4 | 29.9±5.6 | F(3,211) = 3.9598 | .0090 |
| Marital status | P<.0001 | .0717 | |||||
| Single | 46 (21.4) | 1 (9.1) | 3 (25.0) | 5 (10.4) | 37 (25.7) | ||
| Married/cohabiting | 163 (75.8) | 9 (81.8) | 9 (75.0) | 41 (85.4) | 104 (72.2) | ||
| Divorced/separated | 5 (2.3) | 2 (4.2) | 3 (2.1) | ||||
| Widowed | 1 (0.5) | 1 (9.1) | |||||
| Married | 163 (75.8) | 9 (81.8) | 9 (75.0) | 41 (85.4) | 104 (72.2) | P=.0021 | .3092 |
| N children living at home | 0.82±0.99 | 1.89±1.62 | 1.00±1.00 | 0.90±0.93 | 0.71±0.92 | χ2(3)=7.4408 | .0407 |
| Parity | 1.96±1.10 | 2.82±1.47 | 2.00±0.95 | 2.02±0.93 | 1.88±1.11 | χ2(3)=7.4408 | .0591 |
| Lives with | P<.0001 | .0621 | |||||
| Partner, no children | 65 (30.2) | 1 (9.1) | 3 (25.0) | 13 (27.1) | 48 (33.3) | ||
| Partner and children | 99 (46.0) | 8 (72.7) | 6 (50.0) | 29 (60.4) | 56 (38.9) | ||
| Alone, no children | 25 (11.6) | 1 (9.1) | 1 (8.3) | 1 (2.1) | 22 (15.3) | ||
| Alone with children | 20 (9.3) | 1 (9.1) | 2 (16.7) | 2 (4.2) | 15 (10.4) | ||
| Parent(s), no children | 1 (0.5) | 1 (2.1) | |||||
| Parent(s) and children | 5 (2.3) | 2 (4.2) | 3 (2.1) | ||||
| Race | P<.0001 | .0007 | |||||
| White | 171 (79.5) | 10 (90.9) | 6 (50.0) | 46 (95.8) | 109 (75.7) | ||
| Black | 39 (18.1) | 1 (9.1) | 5 (41.7) | 1 (2.1) | 32 (22.2) | ||
| Other | 5 (2.3) | 1 (8.3) | 1 (2.1) | 3 (2.1) | |||
| White race | 171 (79.5) | 10 (90.9) | 6 (50.0) | 46 (95.8) | 109 (75.7) | ||
| Employment/academic status | P<.0001 | .0314 | |||||
| Not at all | 71 (33.2) | 7 (63.6) | 5 (41.7) | 21 (44.7) | 38 (26.4) | ||
| Occasional | 4 (1.9) | 2 (4.3) | 2 (1.4) | ||||
| Part time | 22 (10.3) | 2 (18.2) | 4 (8.5) | 16 (11.1) | |||
| Full time | 117 (54.7) | 2 (18.2) | 7 (58.3) | 20 (42.6) | 88 (61.1) | ||
| Employed/attending school | 143 (66.8) | 4 (36.4) | 7 (58.3) | 26 (55.3) | 106 (73.6) | ||
| Education level | P<.0001 | .0524 | |||||
| High school or less | 40 (18.7) | 1 (9.1) | 5 (41.7) | 7 (14.9) | 27 (18.8) | ||
| Some college | 35 (16.4) | 6 (54.5) | 3 (25.0) | 7 (14.9) | 19 (13.2) | ||
| College | 87 (40.7) | 2 (18.2) | 3 (25.0) | 20 (42.6) | 62 (43.1) | ||
| Graduate school | 52 (24.3) | 2 (18.2) | 1 (8.3) | 13 (27.7) | 36 (25.0) | ||
OVERALL FUNCTIONING
The changes across time for the four measures of function are displayed by exposure group in Figure 1. On the GAS, the scores were reasonably stable over time (ρ = .8137) (Table 2). A significant group effect (P<.0001) was observed, with the nonresponder group having less favorable overall functioning than either the responder (ρ<.0001) or the control (ρ<.0001) groups. Similarly, the untreated group had poorer functioning than the responder (ρ<.0001) or control (ρ<.0001) groups. The responder group displayed a level of function most similar to the control group; however, the control group remained significantly more favorable in comparison (ρ<.0001). There was no differential effect of group over time (ρ = .6834) (Fig. 1A).
Figure 1.
Study outcomes over time.
TABLE 2.
Descriptive statistics for maternal function measures by group and weeks postpartum
| 2 Weeks | 12 Weeks | 26 Weeks | 52 Weeks | All | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Measure/group | N | Mean+SD | N | Mean+SD | N | Mean+SD | N | Mean+SD | N | Mean+SD |
| GAS | ||||||||||
| Nonresponders | 11 | 66.5±9.2 | 7 | 62.0±5.9 | 8 | 59.3±8.9 | 5 | 71.2±7.7 | 31 | 64.4±8.9 |
| Untreated | 11 | 68.2±9.3 | 5 | 63.6±10.3 | 9 | 64.6±9.8 | 8 | 63.1±10.4 | 33 | 65.3±9.6 |
| Responders | 38 | 80.4±7.9 | 30 | 82.9±8.1 | 33 | 81.1±8.6 | 26 | 78.6±11.1 | 127 | 80.8±8.9 |
| Control | 125 | 85.1±7.6 | 105 | 86.7±7.4 | 100 | 86.1±7.0 | 91 | 84.4±9.0 | 421 | 85.6±7.8 |
| All | 185 | 82.0±9.6 | 147 | 84.0±10.0 | 150 | 82.3±10.7 | 130 | 81.4±11.0 | 612 | 82.4±10.3 |
| GRAT | ||||||||||
| Nonresponders | 8 | 3.3±0.5 | 6 | 3.1±0.8 | 5 | 3.9±0.8 | 3 | 3.6±0.6 | 22 | 3.4±0.7 |
| Untreated | 9 | 3.4±0.7 | 4 | 3.9±0.4 | 5 | 4.0±0.5 | 4 | 3.9±0.9 | 22 | 3.7±0.6 |
| Responders | 30 | 3.8±0.8 | 22 | 4.0±0.5 | 25 | 4.2±0.6 | 13 | 4.3±0.4 | 90 | 4.1±0.6 |
| Control | 104 | 3.9±0.7 | 80 | 4.0±0.5 | 74 | 4.2±0.5 | 57 | 4.2±0.6 | 315 | 4.1±0.6 |
| All | 151 | 3.8±0.7 | 112 | 4.0±0.6 | 109 | 4.2±0.5 | 77 | 4.2±0.6 | 449 | 4.0±0.6 |
| ICS | ||||||||||
| Nonresponders | 8 | 99.8±61.2 | 6 | 87.0±31.9 | 7 | 79.3±23.7 | 2 | 65.5±12.0 | 23 | 87.2±41.3 |
| Untreated | 9 | 118±60.9 | 4 | 99.5±31.5 | 6 | 89.5±31.5 | 4 | 136±78.7 | 23 | 10±53.3 |
| Responders | 26 | 83.2±23.5 | 19 | 76.2±24.4 | 24 | 72.4±21.7 | 15 | 76.1±23.0 | 84 | 77.3±23.1 |
| Control | 104 | 97.2±36.0 | 90 | 84.0±26.8 | 78 | 79.0±29.0 | 49 | 69.9±19.9 | 321 | 84.9±31.1 |
| All | 147 | 96.1±38.1 | 119 | 83.4±26.8 | 115 | 78.2±27.4 | 70 | 74.9±29.8 | 451 | 84.9±32.5 |
| IFSAC | ||||||||||
| Nonresponders | 8 | 2.9±0.4 | 7 | 3.2±0.5 | 6 | 3.2±0.2 | 4 | 3.7±0.4 | 25 | 3.2±0.4 |
| Untreated | 9 | 2.8±0.4 | 4 | 3.0±0.2 | 6 | 3.2±0.3 | 4 | 3.2±0.2 | 23 | 3.0±0.4 |
| Responders | 28 | 3.0±0.5 | 24 | 3.3±0.3 | 27 | 3.3±0.3 | 18 | 3.5±0.3 | 97 | 3.2±0.4 |
| Control | 108 | 2.9±0.4 | 93 | 3.2±0.2 | 81 | 3.2±0.2 | 71 | 3.5±0.4 | 353 | 3.2±0.4 |
| All | 153 | 2.9±0.4 | 128 | 3.2±0.3 | 120 | 3.2±0.2 | 97 | 3.5±0.4 | 498 | 3.2±0.4 |
GAS, Global Assessment Scale; scores range from 1 to 100 with higher scores = higher functioning; GRAT, Gratification in role of mother; higher scores indicate higher gratification; ICS, Infant Care Scale. Lower scores indicate higher self-efficacy; IFSAC, Inventory of Functional Status after Childbirth. Higher scores indicate high functioning.
GRATIFICATION
On the GRAT, a significant group effect (ρ = .0002) was observed, with the nonresponders functioning significantly less than responders (ρ = .0003) and controls (ρ = .0005). There was also a significant association with time (ρ = .0001), with the 2-week scores significantly different than the 26 (ρ<.0001) and 52 (ρ<.0001) week scores and the 12-week scores significantly different than the 26-week scores (ρ = .0013). There was no differential effect of group over time (ρ = .5855) (Fig. 1B).
SELF-EFFICACY
No differences in ICS scores were observed across groups (ρ = .1841). The significant association of time (ρ<.0001) denotes the decrease in scores (improvement) across the first year. Post hoc comparisons show the 2-week scores were significantly different from the 12-, 26-, and 52-week scores (ρ = .0002, ρ<.0001, ρ<.0001, respectively). In addition, the 12-week scores were significantly different from the 26- and 52-week scores (ρ = .0018, ρ<.0001, respectively). There was no differential effect of group over time (ρ = .4021) though the untreated group had an increase at 52 weeks, which was likely due to one outlier (who rated all items at the highest score) in a small sample (Fig. 1C).
FUNCTIONAL STATUS AFTER CHILDBIRTH
The IFSAC scores did not differ across groups (ρ = .0549). There was a significant association with time (ρ<.0001), which demonstrates improvement in all groups over the 12 months. Post hoc comparisons showed that the 2-week score significantly differed from the 12- (ρ<.0001), 26- (ρ<.0001), and 52-week (ρ<.0001) scores, the 12- and 26-week scores significantly different from the 53-week scores (ρ<.0001 for both) (Fig. 1D).
DISCUSSION
In this prospective, observational study of women across 12 months postpartum, we found that the GAS and the GRATwere the two measures that significantly differed by group. Our hypothesis that women with MDD who responded to SSRIs would function similarly to the control group and superior to nonresponders and untreated women with MDD was supported by data from both the GAS and the GRAT. The scores on these measures are meaningfully different; for example, the GAS mean score for controls and responders was in the 81–90 decile, which is characterized by “absent or minimal symptoms (e.g. mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns” (e.g. an occasional argument with family members). The nonresponders and women with untreated MDD had scores in the 61–70 decile, characterized by “some mild symptoms (e.g. depressed mood and mild insomnia) OR s ome difficulty in social, occupational, or school functioning (e.g. occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships.”[33]
High total scores on the GRAT reflect that life has improved since the baby’s birth in the area of relationships (e.g. more things to talk to spouse about, feeling close to spouse, relationships with relative closer, increased contact with neighbors, and new appreciation of own parents) and general enjoyment of life (e.g. fewer periods of boredom, feeling of fulfillment, and purpose for living). Several items also depict pleasure with baby (e.g. enjoy baby’s company, pride in baby’s development, and baby fun to play with). The scores of the responders and the control group were essentially identical at every time interval and differed from the other two groups across time (mean differences range from 2 to 9 points).
Neither the ICS nor IFSAC differentiated among the groups of participants, though scores from both measures improved across time as would be expected. The Infant Care Survey (ICS) was developed to measure maternal self-efficacy related to infant care. This aspect of function may be preserved in mild to moderate level maternal depression[40] and may not be a comprehensive measure of maternal function. Although the IFSAC was designed to assess maternal functional status, its definition is dependent on a woman’s resumption of the roles she had prior to birth and does not take into account that roles may adaptively change, nor does it include an assessment of the mother’s feeling state, which is important to functioning.[41]
Several other publications have considered functioning in postpartum women, but only our research team has comprehensively measured functioning as a result of antidepressant treatment. For example, the challenges in functioning for postpartum women were also demonstrated by the Childbirth Connection’s New Mothers Speak Out survey[42] which found that mothers in the United States experience social, physical, and emotional challenges that persist across the first two postpartum years. At 6 months postpartum, women had problems such as feeling stressed (43% of all mothers) weight control (40%), sleep loss (34%), lack of sexual desire (26%), physical exhaustion (25%), backache (24%), and pain at the incision site (18% of women with surgical births). Women were not getting enough exercise (49%) or eating a healthy diet (23%). A validated screening tool for postpartum depression, the Edinburgh Postnatal Depression Scale (EPDS≥13)[43] was positive in 23% of women at <6 months postpartum, 17% at 7–12 months, 17% at 13–18 months, and 20% at 19–24 months.
The extent (and rapidity) to which domains of functioning improve is important to reduce the short and long-term impact of the disorder upon the mother, infant, and family. As defined by new mothers through focus groups,[41] “a woman who (1) has adequate social support (social support) and is able to (2) take care of her own physical (self-care) and mental needs (psychological well-being), (3) take care of her infant (infant care), (4) attach to her infant (mother–child interaction), (5) juggle her various responsibilities (management), and (6) adapt over time (adjustment) is functioning optimally.”
CONCLUSIONS
Our study has several strengths, including its prospective design and the inclusion of measures that assess different functional domains. Additionally, the group of women treated with SSRIs had serum level documentation of their compliance with the antidepressant.[29] The women were diagnosed as having depression according to the SCID, a research psychiatric diagnostic interview. The study follows international guidelines which recommend that the effects of depression treatment on families, as well as mothers, should be evaluated in all future research.[44–46] In addition, the study advances the science in the area of effects of depression treatment upon overall functioning and maternal role functioning.[44]
Although novel, the study is limited by the small sample sizes in the treatment groups. In addition, the convenience sample and demographics of the sample limit the generalizability of study findings.
There are several implications for clinical practice. First, postpartum depression treatment should target general and specific maternal functional outcomes as well as depressive symptoms to monitor the effectiveness of treatment. Second, the GRAT is a simple, self-administered instrument that can be used across settings to measure maternal role functioning. Mothers without depressive symptoms and functioning well in all desired roles are able to effectively mother their infants and achieve their own developmental tasks and goals, a worthy goal indeed.
Footnotes
The authors report they have no financial relationships within the past 3 years to disclose.
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