Research reportDiagnosing postpartum depression in mothers and fathers: whatever happened to anxiety?
Introduction
Postnatal depression (PND) occurs in 10–20% of new mothers, typically within the first 6 months postpartum (O’Hara and Swain, 1996). Detection of this mood disorder is usually carried out using an initial screening instrument, such as the Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987), followed by a diagnostic interview to confirm whether or not the woman meets DSM-IV or RDC criteria for major or minor depression. This protocol has been used in many studies, for example Cox et al. (1993) and Gotlib et al. (1989). More recently, some studies simply report the percentage of women scoring 13 or more on the EPDS (e.g. Zelkowitz and Milet, 1995), a score which is validated against diagnostic criteria for depression only (e.g. Boyce et al., 1993, Cox et al., 1987). In both protocols, therefore, the ‘gold standard’ used is whether the women meet, or are presumed to meet, criteria for depression.
In the original description of such affective disorders in new mothers, Pitt (1968) reported a mixture of depressive and anxiety symptoms and described the women as having ‘atypical depression’. He reported between 10 and 11% of his sample were depressed while an additional 6% were considered ‘not definitely depressed’ and were classified as: (i) anxiety states unaccompanied by depression, (ii) anxiety and depression purely reactive to the baby’s ill-health, (iii) prolonged fatigue in the absence of other evidence of depression or anaemia, (iv) the development or recurrence of possibly psychosomatic disorders, and (v) diminution of libido as a single symptom. Anxiety accompanied by depression was clearly classified as depression. In 1985, Pitt described postnatal (neurotic) depression as “…a state of weary, irritable despondence…(with) much anxiety over the baby” (Pitt, 1985). He also reported that phobic and obsessional symptoms were common and, at times, very persistent.
Margison (1982) described as common the “highly anxious mother with mild depressive symptoms and intense fears of not coping” (p. 207), noting that such women did well if adequate, timely support was provided. Stuart et al. (1998), in their description of the symptoms of postpartum depression, include ‘intense anxiety’. In that community sample study, they reported a “high prevalence of both anxiety and depressive symptoms in the postpartum period” (p. 423). Such symptoms have also been noted by others in describing the experiences of new mothers (e.g. Astbury, 1994, Green, 1998).
Case descriptions of panic disorder in the puerperium have been reported (e.g. Metz et al., 1988, Altshuler et al., 1998), with a typical pattern being that of the mother unable to leave the house, and at the same time feeling fearful of harming her baby. Such intrusive thoughts have been reported as obsessive-compulsive disorder (OCD) symptoms in new mothers by Sichel et al. (1993) and Wisner et al. (1999), though it appears that again self-report is the method used to determine that the women are suffering from OCD. Women meeting criteria for major depression may indicate that the panic attacks they experience, frequently reported as occurring in the early hours of the morning, are harder to bear than the depressed mood. They may be terrified of harm befalling the baby (including possible harm perpetrated by the mother herself), or the partner or themselves. At times a panic attack is precipitated by the approach of feeding time or by the infant starting to cry, that is, cues signalling the need for some attention from the mother.
The evidence of anxiety disorders in the postpartum period led Shear and Oommen (1994) to state that “the postpartum period appears to represent a period of increased risk for onset or worsening of anxiety disorders” (p. 693). Given the recognition that significant anxiety may also be present in new mothers, it is somewhat puzzling that most researchers use only the Depression modules of diagnostic interviews, and not the Anxiety modules. While Stuart et al. (1998) comment that “postpartum anxiety is not as well studied as postpartum depression” (p. 421), their investigation of the prevalence of both depressive and anxiety disorders in new mothers is based on self-report scales, not on a diagnostic interview. At 14 weeks postpartum, their study found rates for depression of 23.3% (using the Beck Depression Inventory; BDI; Beck et al., 1961) and for anxiety 8.7% (using the STAI: Spielberger et al., 1970). Unfortunately in this study there is no indication of the rate of comorbidity of these disorders, and whether or not all those reporting high anxiety also report high depressive symptomatology. They used the EPDS, which, while it has only been validated against criteria for depression, does (like many other depression scales) include anxiety items. They concluded that the EPDS “may be a good screening tool for both anxiety and depression” (Stuart et al., 1998; p. 422). Contrary to this opinion, however, is the work of Muzik et al. (2000). They showed that women with anxiety disorders scored significantly lower on the EPDS than women with a major depressive disorder by an average of five points. Their research also indicated that there was very little comorbidity of depression and anxiety disorders in new mothers, and thus they concluded that “further research is clearly needed in order to identify or create screening measures for postpartum anxiety disorders” (p. 73).
Robinson and Young (1982) used the self-report Leeds scale (Snaith et al., 1976), and reported that in their sample of 284 mothers with 6- to 8-week-old babies, 7.4% of the sample had pure anxiety without scoring high on depression, while only 1.7% scored high on depression and not anxiety. A recent epidemiological study in Australia found that of men and women with an anxiety disorder, around half had no comorbidity with depression (Andrews et al., 1999).
Recent research also suggests that comorbidity of these disorders (‘anxious depression’) in non-childbearing samples is harder to treat than either disorder alone, and may therefore require a different treatment strategy (Emmanuel et al., 1998). Such findings may have equivalent treatment implications in postpartum adults. Matthey et al. (2001) have also suggested that in new fathers anxiety may be a more common reaction than depression. Couple concordance for postpartum depression has been reported to be higher when the father, as opposed to the mother, is the index case (Raskin et al., 1990, Matthey et al., 2000). As yet, no studies have reported on whether this picture remains the same when postpartum anxiety disorders are assessed. Assessment of both disorders, rather than just depression, would therefore be warranted when investigating the mental well-being of expectant or new parents.
This paper reports the result of assessing for depression (major or minor) and the anxiety disorders of panic, acute adjustment disorder with anxiety (generalised anxiety disorder criteria except for duration), and phobia, in first-time parents, and provides evidence that ignoring the anxiety disorders significantly underestimates the rate of adjustment difficulties in new mothers and fathers. In addition, rates of couple concordance are reported for the depressive and anxious disorders, and the causal pathway of the development of these disorders is investigated with respect to antenatal mood and retrospective reporting of histories of both types of disorders.
Section snippets
Participants
Two samples of first-time mothers and fathers were recruited from antenatal classes in a public hospital in South West Sydney, as part of a study investigating prevention strategies for postnatal mood disorders (PMD: depression or anxiety disorders). Sample 1 was randomly allocated to one of three conditions, investigating a psychosocial prevention program for PMD. Those in Sample 2 were randomly allocated to one of two conditions, also investigating a psychosocial intervention. Uptake rates
Results
Table 2 shows the rates of mothers and fathers meeting criteria for the different disorders at 6 weeks postpartum. For those with an anxiety disorder but no depressive disorder, the breakdown of which anxiety disorder was present is given in Table 3. As these results show, assessing for the presence of anxiety disorders greatly increases the rate of women and men having distress to the level of caseness, and for both genders it is the presence of specific phobias that greatly inflates these
Discussion
Classification of depressive disorders remains a controversial topic, but ‘anxious depression’ has been described in the literature for many years (e.g. Goldberg, 1999, Overall et al., 1966). Clinically it is well recognised that anxiety and depression, both as affective states and as clinical disorders, frequently overlap. Standardised scales also implicitly acknowledge this aspect. In cases of anxiety and depressive syndromes seen in the primary care setting, around 50% occur simultaneously
Conclusion
Most postpartum studies report only the woman’s depression, and the results of this study show that many women, and men, do not have clinical depression but do have anxiety disorders. Concluding that these individuals are functioning well because they are not depressed is incorrect. No clinical psychiatric assessment would be considered complete without inquiring about anxiety symptoms, and screening measures offered perinatally must include such disorders. The EPDS is often used to screen for
Acknowledgements
This project was funded by a grant from the Commonwealth Department of Health and Family Services (Research section), Australia, and Karitane, Australia.
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