Depressive Symptoms During the First Year Postpartum

Winstone-Weide, L. K., Somers, J. A., Curci, S. G., & Luecken, L. J. (2023). A dynamic perspective on depressive symptoms during the first year postpartum. Journal of Psychopathology and Clinical Science, 132(8), 949–960. https://doi.org/10.1037/abn0000878

Key Points

• The study examined intraindividual variability in postpartum depressive (PPD) symptoms among low-income Mexican-origin mothers across the first year postpartum.
• Factors like prenatal cumulative risk, infant temperamental negativity, and prenatal depressive symptoms significantly affected mothers’ equilibrium (mean level), carryover (persistence), and volatility (fluctuations) of PPD symptoms.
• Mothers with higher prenatal risk, more negative infant temperament, and higher prenatal depressive symptoms experienced higher equilibrium and more volatility in PPD symptoms.
• The research, while enlightening, has certain limitations such as reliance on maternal self-report and potential lack of generalizability to other populations.
• Understanding the dynamic nature of PPD symptoms is crucial for improving screening, intervention, and support for mothers during the postpartum period.

Rationale

Postpartum depression (PPD) affects an estimated 17-18% of mothers globally, with higher rates (33-53%) among low-income Hispanic mothers in the United States (Gress-Smith et al., 2012; Hahn-Holbrook et al., 2018).

PPD has significant implications for maternal well-being, caregiving behaviors, and long-term child outcomes (Netsi et al., 2018).

While previous research has examined mean levels of PPD symptoms at various time points, less is known about the intraindividual variability in symptom experience across the postpartum period.

Recent studies have highlighted the importance of capturing variability in maternal mood and its impact on child outcomes (Glynn et al., 2018, 2019).

However, little is known about factors contributing to intraindividual maternal mood variability, particularly in high-risk populations.

This study aimed to address this gap by characterizing within-person fluctuations in PPD symptoms and examining the roles of prenatal cumulative risk and infant temperament as contributors to symptom dynamics among low-income Mexican-origin mothers.

Understanding the dynamic nature of PPD symptoms and identifying factors that influence symptom patterns can inform more effective screening protocols, intervention strategies, and support systems for mothers during the postpartum period.

This research extends previous work by employing novel methodological approaches to capture the complexity of PPD symptom experiences in a traditionally underserved population.

Method

The study used a dynamic structural equation modeling (DSEM) framework to examine intraindividual variability in PPD symptoms across the first year postpartum.

Procedure

Participants were assessed at multiple time points:

• Prenatal home visit (26-38 weeks gestation)
• Five postpartum home visits (6, 12, 18, 24 weeks, and 12 months)
• Six phone calls (3, 9, 15, 21, 27 weeks, and 9 months postpartum)

Sample

322 low-income Mexican-origin mothers (mean age = 27.79 years, SD = 6.48)

• 86% born in Mexico, 14% born in the United States
• 30% married and living together, 45% living with partner but not married, 15% never married and not living with a partner
• Annual income: 14% ≤$5,000, 19% $5,001-10,000, 28% $10,001-15,000, 12% $15,001-20,000, 13% $20,001-25,000, 14% ≥$25,001

Measures

1. Edinburgh Perinatal Depression Scale (EPDS): 10-item measure of PPD symptoms
2. Economic Hardship Scale: measure of familial economic stress
3. Pregnancy Risk Assessment Monitoring System (PRAMS): assessed interpersonal violence and negative life events during pregnancy
4. Perceived Stress Scale: 4-item version measuring perceived stress
5. Hispanic Stress Inventory: assessed cultural stress
6. Family negativity: 3 items modified from Midlife in the United States survey
7. Neighborhood concentrated disadvantage: calculated using census data
8. Infant Behavior Questionnaire (IBQ)-Revised: assessed infant temperamental negativity at 6 weeks postpartum

Statistical measures

• Multilevel location scale analyses in a dynamic structural equation modeling (DSEM) framework
• Bayesian methods for model estimation
• Random effects placed on intercepts (equilibrium), autoregressive slopes (carryover), and intraindividual residual variances (volatility)

Results

Hypothesis 1: Mothers will exhibit significant intraindividual variability in PPD symptoms across the first year postpartum.

Results: Confirmed.

• Mothers showed nonnull positive carryover (γ10 = 0.28, 95% CrI [0.23, 0.33]) and significant volatility (exp(ω00) = 3.67) in PPD symptoms.

Hypothesis 2: Prenatal cumulative risk, infant temperamental negativity, and prenatal depressive symptoms will predict higher equilibrium, greater carryover, and more volatility in PPD symptoms.

Results: Partially confirmed.

• Higher prenatal cumulative risk predicted higher equilibrium (γ02 = 0.47, 95% CrI [0.24, 0.69]) and more volatility (ω2 = 1.22) in PPD symptoms.
• Higher infant temperamental negativity predicted higher equilibrium (γ03 = 0.36, 95% CrI [0.08, 0.64]) and more volatility (ω3 = 1.75) in PPD symptoms.
• Higher prenatal depressive symptoms predicted higher equilibrium (γ01 = 0.22, 95% CrI [0.17, 0.28]), greater carryover (γ11 = 0.01, 95% CrI [0.00, 0.02]), and more volatility (ω1 = 1.14) in PPD symptoms.

Hypothesis 3: Equilibrium, carryover, and volatility in PPD symptoms will be significantly correlated.

Results: Confirmed.

• Mothers with higher equilibrium of PPD symptoms showed more volatility (τ20 = 1.85, 95% CrI [1.51, 2.34]) and more carryover (τ10 = 0.25, 95% CrI [0.14, 0.36]).
• Mothers with more carryover showed more volatility (τ21 = 0.18, 95% CrI [0.10, 0.27]).

Insight

This study provides a novel characterization of the dynamic nature of PPD symptoms among low-income Mexican-origin mothers.

The findings reveal significant intraindividual variability in symptom experience, with mothers showing both persistence (carryover) and fluctuations (volatility) in their PPD symptoms across the first year postpartum.

The research extends previous work by demonstrating that prenatal cumulative risk and infant temperamental negativity contribute to the dynamics of PPD symptoms.

Mothers with higher prenatal risk and infants with more negative temperament experienced higher overall levels of PPD symptoms and more pronounced fluctuations in symptoms over time.

This highlights the importance of considering both maternal and infant factors in understanding the course of PPD.

The study’s use of dynamic structural equation modeling offers a more nuanced perspective on PPD symptom patterns compared to traditional approaches that focus solely on mean levels.

This approach allows for the identification of different “phenotypes” of PPD symptom experience, which may have implications for targeted screening and intervention strategies.

Future research could explore:

1. The impact of PPD symptom dynamics on long-term maternal and child outcomes
2. The effectiveness of interventions tailored to different PPD symptom patterns
3. The role of protective factors in moderating the effects of risk on PPD symptom dynamics
4. Cross-cultural comparisons of PPD symptom dynamics and contributing factors

Strengths

1. Use of intensive longitudinal design with multiple assessments across the first year postpartum
2. Application of advanced statistical techniques (DSEM) to capture complex symptom dynamics
3. Inclusion of both maternal (prenatal risk) and infant (temperament) factors as predictors
4. Focus on an understudied, high-risk population of low-income Mexican-origin mothers
5. Consideration of cumulative psychosocial risk rather than individual risk factors in isolation

Limitations

1. Reliance on maternal self-report for both PPD symptoms and infant temperament, which may introduce bias
2. Limited generalizability to other populations (e.g., different socioeconomic or ethnic backgrounds, fathers, or non-biological parents)
3. Lack of clinical diagnosis of PPD, focusing instead on symptom levels
4. Potential confounding effects of cultural factors on symptom reporting and interpretation
5. Absence of data on protective factors or resilience that may influence PPD symptom dynamics

These limitations suggest the need for future studies using multi-informant assessments, clinical interviews, and more diverse samples to corroborate and extend the current findings.

Clinical Implications

The study’s findings have real-world impact by informing more nuanced and personalized approaches to supporting maternal mental health during the postpartum period.

By recognizing the complex interplay of risk factors and symptom dynamics, healthcare providers and policymakers can develop more effective strategies to prevent and address PPD, ultimately promoting better outcomes for mothers, infants, and families.

1. Screening protocols: The study highlights the need for frequent, repeated screenings for PPD symptoms throughout the first year postpartum, as opposed to one-time assessments. This can help capture the dynamic nature of symptom experience and identify mothers who may be at risk due to high volatility or persistent symptoms.
2. Targeted interventions: Understanding different patterns of PPD symptom dynamics can inform the development of tailored interventions. For example, mothers with high volatility in symptoms may benefit from strategies to enhance emotional regulation, while those with high carryover might require more intensive, sustained support.
3. Prenatal risk assessment: The findings underscore the importance of comprehensive prenatal psychosocial risk assessment. Identifying mothers with high cumulative risk during pregnancy could facilitate early intervention and support to mitigate postpartum difficulties.
4. Infant-focused approaches: The association between infant temperamental negativity and maternal PPD dynamics suggests that interventions targeting infant regulation and mother-infant interaction may have positive effects on maternal mental health.
5. Cultural considerations: The focus on Mexican-origin mothers highlights the need for culturally sensitive approaches to PPD screening, prevention, and intervention in diverse populations.
6. Integrative care: The results support the need for integrated perinatal care that addresses both maternal mental health and infant development, recognizing the bidirectional influences between mother and child well-being.
7. Public health education: Raising awareness about the dynamic nature of PPD symptoms can help normalize the experience for mothers and encourage help-seeking behaviors.

References

Primary reference

Winstone-Weide, L. K., Somers, J. A., Curci, S. G., & Luecken, L. J. (2023). A dynamic perspective on depressive symptoms during the first year postpartum. Journal of Psychopathology and Clinical Science, 132(8), 949–960. https://doi.org/10.1037/abn0000878

Other references

Glynn, L. M., Howland, M. A., Sandman, C. A., Davis, E. P., Phelan, M., Baram, T. Z., & Stern, H. S. (2018). Prenatal maternal mood patterns predict child temperament and adolescent mental health. Journal of Affective Disorders, 228, 83-90.

Glynn, L. M., Stern, H. S., Howland, M. A., Risbrough, V. B., Baker, D. G., Nievergelt, C. M., Baram, T. Z., & Davis, E. P. (2019). Measuring novel antecedents of mental illness: The Questionnaire of Unpredictability in Childhood. Neuropsychopharmacology, 44(5), 876-882.

Gress-Smith, J. L., Luecken, L. J., Lemery-Chalfant, K., & Howe, R. (2012). Postpartum depression prevalence and impact on infant health, weight, and sleep in low-income and ethnic minority women and infants. Maternal and Child Health Journal, 16(4), 887-893.

Hahn-Holbrook, J., Cornwell-Hinrichs, T., & Anaya, I. (2018). Economic and health predictors of national postpartum depression prevalence: A systematic review, meta-analysis, and meta-regression of 291 studies from 56 countries. Frontiers in Psychiatry, 8, 248.

Netsi, E., Pearson, R. M., Murray, L., Cooper, P., Craske, M. G., & Stein, A. (2018). Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry, 75(3), 247-253.

Keep Learning

1. How might the dynamic nature of PPD symptoms influence our approach to diagnosis and treatment compared to traditional static models of depression?
2. In what ways could the findings on infant temperament and maternal PPD dynamics inform early intervention strategies for both mother and child?
3. How might cultural factors specific to Mexican-origin mothers influence the experience and reporting of PPD symptoms, and how can this inform culturally sensitive interventions?
4. What ethical considerations should be taken into account when implementing more frequent PPD screenings throughout the postpartum period?
5. How might the concept of cumulative prenatal risk be applied to other areas of mental health research and intervention?
6. In what ways could future research address the limitations of this study to further our understanding of PPD dynamics across diverse populations?