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Exploring the heterogeneity inclinical presentation and functionalimpairment of postpartum depressionQuetzal A. Class a , Johan Verhulst b & Julia R. Heiman a ba Department of Psychological and Brain Sciences , IndianaUniversity , Bloomington , Indiana , USAb The Kinsey Institute for Research in Sex, Gender andReproduction , Indiana University , Bloomington , IN , USAPublished online: 08 May 2013.

To cite this article: Quetzal A. Class , Johan Verhulst & Julia R. Heiman (2013) Exploring theheterogeneity in clinical presentation and functional impairment of postpartum depression, Journalof Reproductive and Infant Psychology, 31:2, 183-194, DOI: 10.1080/02646838.2013.795217

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Exploring the heterogeneity in clinical presentation and functionalimpairment of postpartum depression

Quetzal A. Classa*, Johan Verhulstb and Julia R. Heimana,b

aDepartment of Psychological and Brain Sciences, Indiana University, Bloomington, IN,USA; bThe Kinsey Institute for Research in Sex, Gender and Reproduction,

Indiana University, Bloomington, IN, USA

(Received 17 August 2012; final version received 1 April 2013)

Objective: Examine the spectrum of postpartum psychiatric conditions with theaim to evaluate the current use of a postpartum onset specifier. Background:The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, textrevision (DSM-IV-TR) uses an onset specifier to categorise a limited number ofpsychiatric diagnoses as postpartum onset. Diagnoses and clinical symptomatol-ogy, however, may be more complex than what the DSM-IV-TR allows.Methods: A total of 59 women aged 19–41 years were recruited 3–6 monthspostpartum. Women completed questionnaires and those scoring possiblydepressed, identified by scoring at least 10 (30 maximum) on the EdinburghPostnatal Depression Scale, participated in semi-structured psychiatric evalua-tions. Degree of functional impairment was rated on a three-point scale. Results:Possibly depressed women did not differ from healthy controls on several back-ground characteristics. Postpartum diagnoses were heterogeneous; only 46% ofpossibly depressed women received a diagnosis of major depression. Otherdiagnoses included depressive disorder not otherwise specified, adjustment disor-der, anxiety disorder not otherwise specified, alcohol dependence, and twowomen did not qualify for a diagnosis. Functional impairment did not differacross diagnoses. A diathesis-stress perspective aided understanding of the clini-cal expression of psychopathology and creating clinical case formulations.Conclusions: The limited application of a postpartum onset specifier is unsatis-factory. Unless the diverse range of postpartum disorders is properly acknowl-edged by considering a diathesis–stress perspective and allowing for an onsetspecifier, the care of women experiencing psychological distress during the post-partum period may have reduced effectiveness and future research will behindered.

Keywords: Postpartum depression; postpartum care; psychosocial factors;interviews; mothers

Introduction

The postpartum period is a time of great change for the mother and her infant.While expanding a family can be a positive experience, childbearing also involvesunique and extensive psychological and physical adjustments. During the postpar-tum period, a woman encounters not only psychosocial stressors such as new

*Corresponding author. Email: qaclass@indiana.edu

Journal of Reproductive and Infant Psychology, 2013Vol. 31, No. 2, 183–194, http://dx.doi.org/10.1080/02646838.2013.795217

� 2013 Society for Reproductive and Infant Psychology

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responsibilities, the need to attain a maternal identity (Koniak-Griffin, 1993; Mercer,1985) and relationship challenges with one’s partner, one’s family and new child,but also biological stressors such as reduced and interrupted sleep patterns, physicalexhaustion, dramatic hormonal shifts (Brunton & Russell, 2010; Workman, Barha,& Galea, 2012) and varying degrees of birthing trauma. Further, these stressorsoccur after the body has already performed the demanding task of carrying a foetusto term. Thus, the postpartum period is clearly a period of increased vulnerability(Hammen, 2005; Selye, 1974).

In the majority of women, postpartum stress triggers fairly manageable symp-toms such as emotional lability and the ‘baby blues’. However, for 9–23% of newmothers, the level of stress and change causes clinical levels of impairment that typ-ically manifests as a depressive episode (Gavin et al., 2005; Paulson & Bazemore,2010). Clinical depression after the birth of a child not only causes suffering butalso impedes the mother’s ability to bond with the baby and to enjoy the maternalexperience (Barrett & Fleming, 2011) and, for the infant, may lead to increased irri-tability, decreased cognitive ability (Whiffen & Gotlib, 1989), altered stress-respon-siveness (Diego et al., 2004) and increased risk for internalising behaviourproblems (Bagner, Pettit, Lewinsohn, & Seeley, 2010; Goodman, 2007).

Thus, the postpartum period is uniquely, and sometimes overwhelmingly, stress-ful and can induce psychological symptoms of varying severity. A diathesis–stress–resilience framework may therefore be particularly useful to understand women’spostpartum experiences: whether or not a woman will decompensate and experiencesevere postpartum psychopathology depends upon the interaction between (a) thepresence or absence of a diathesis, i.e. a susceptibility, for mental health problems,which is related to genetic factors and/or to personality traits and early childhoodadverse events that induce lasting changes in stress responsiveness (Gutman &Nemeroff, 2003; Hankin & Abela, 2005; Skopen, McLaughlin, Zeenah, & Nelson,2012), (b) the amount and intensity of the current biopsychosocial stress that shehas encountered, and (c) her stress resilience, coping skills and resources includingher support network as well as financial and other assets.

This theoretical framework is particularly useful in the construction of a clinicalcase formulation, which complements the diagnostic approach of the Diagnosticand Statistical Manual of Mental Disorder, fourth edition, text revision (DSM-IV-TR). The DSM-IV-TR recognises that there is no specific postpartum syndromecharacterised by distinct psychiatric phenomenology. Instead, the postpartum periodappears to be a period of special vulnerability in which several mental disorderscan become activated. A diagnosing clinician notes this by applying a ‘postpartumonset specifier’ to a diagnosis of major depression, mania, bipolar I, bipolar II, orbrief psychotic episode if these conditions develop within 4 weeks of delivery(American Psychiatric Association., 2000). The onset specifier draws only modestattention to the unique stress and vulnerability of the postpartum period. Further,psychiatric conditions such as anxiety and adjustment disorders commonly occur inthe postpartum population, but without the ability to apply the same specifier in theDSM-IV-TR they may not qualify as postpartum-related disorders. Although previ-ous research has supported an expansion of the specifier (Brockington, 2011; Shar-ma & Burt, 2011) and a new edition of the DSM is in preparation to be released in2013, no major changes in the criteria for the postpartum specifier are anticipated.

To add to the confusion, patients and physicians tend to use the term ‘postpar-tum depression’ to refer not only to clinical depression but also to a broad range

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of psychological disorders (Mauri et al., 2010; Weinstock & Cohen, 2003).Consequently, it has been suggested that the construct of postpartum depression bechanged to ‘perinatal mood distress’ or ‘puerperal mood disturbance’ (Brouwers,Van Baarb, & Popc, 2001; Mauri et al., 2010; Ross, Evans, Sellers, & Romach,2003; Weinstock & Cohen, 2003). These constructs have limited clinical usefulness,however, as they ignore the distinct phenomenology of the various postpartum-related disorders. The lack of conceptual clarity may hinder or confuse researchagendas, delay proper psychological and medical treatment, and distort how societyand the media view postpartum-related conditions.

In the current study, women suspected to be presenting with postpartumdepression were evaluated psychiatrically as part of a larger study on the neuropsy-chological functioning of postpartum women. The comprehensive evaluationendeavoured to (a) understand how the participant experienced the postpartum chal-lenges and symptoms, (b) determine if she met criteria for a clinical psychiatricdiagnosis, (c) appraise the usefulness of the diathesis–stress–resilience framework inconstructing a clinical formulation, and (d) assess the degree of functional impair-ment brought about by the illness.

Methods

After Institutional Review Board approval, women were recruited via flyers, localorganisations, and email promotion across the local campus and community settingas part of a larger study using functional magnetic resonance imaging (fMRI).Participants were restricted to heterosexual women currently in relationships, aged20–40 and 3–6 months postpartum. Following informed consent, all participantswere given the 10-question Edinburgh Postnatal Depression Scale (EPDS; Cox,Holden, & Sagovsky, 1987) as a phone screen and on the day of testing. The EPDSis the primary screening tool for postpartum depression used by researchers andhealthcare professionals (Brouwers et al., 2001; Figueira, Correa, Malloy-Diniz, &Romano-Silva, 2009; Gibson, McKenzie-McHarg, Shakespeare, Price, & Gray,2009; Ji et al., 2011; Muzik et al., 2000; Rowe, Fishe, & Loh, 2008). Higher scoresindicated greater levels of symptoms. On the day of testing, if a participant scored10 or higher (30 maximum) on the EPDS they qualified as ‘possibly depressed’(PossDep; Figueira et al., 2009; Gibson et al., 2009) and participated in a psychiat-ric evaluations performed by a psychiatrist (J.V.) and/or a trained, advanced clinicalpsychology doctoral student (Q.C.). Before diagnoses were assigned, evaluators metto discuss the cases and reach consensus on diagnosis and clinical formulation.Participants who scored low on the EPDS were included in the non-depressed(NonDep) group and completed questionnaires, but did not go on to engage in psy-chiatric evaluations. Because possibly depressed women are rare in the population,enrolment of possibly depressed women continued longer than for postpartumhealthy women with the aim of enrolling similar numbers of participants by group.

The semi-structured psychiatric evaluations lasted from 45 to 60 min. Theprimary aim of the evaluation was to understand how the participant experiencedher symptoms and postpartum challenges. The evaluators asked about the presenceof a personal and/or family history of psychiatric illness, major childhood events,the participants’ school, work and health history, current alcohol and substance use,suicidality, and current life circumstances. The evidence of diathesis, life stresses,coping style and resilience was then summarised in a clinical case formulation

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(see vignettes for example passages). Assessing the level of stress is relativelysubjective as the impact of a stressful event depends on the meaning that theindividual ascribes to it (Lazarus, 1984). Additionally, determining the presence ofdiathesis remains imprecise because many diatheses may be present to varyingdegrees. In spite of subjectivity and imprecision, a clinical case formulation hasbeen shown to be preferable to a diagnostic label for prognosis and treatmentplanning (Macneil, Hasty, Conus, & Berk, 2012; Regier et al., 1998). Thesemi-structured format of the evaluation also allowed for primary diagnoses besidesmajor depression to be identified and for across-participant patterns of symptoms toemerge. For example, systematic inquiries about issues with breastfeeding werebegun halfway through participant recruitment because a potential pattern emergedwhen breastfeeding difficulties appeared particularly prevalent in the PossDepgroup. At the end of each evaluation, the evaluators were able to providerecommendations for therapeutic or community support.

In addition to background questions, the 20-question Experience of MotherhoodQuestionnaire (EMQ) was used to assess level of successful coping and emotionalwell-being in the new mothers (Astbury, 1994). Higher scores indicated bettercoping and emotional well-being. Clinical impairment was ranked following thecompletion of all evaluations by both evaluators’ consensus. Impairment operation-alisation is presented in Table 1.

Results

Between-group analyses

A total of 61 postpartum women were recruited; 26 women qualified for thePossDep group while 33 qualified for the NonDep group. Two women that qualifiedas postpartum depressed dropped out due to claustrophobia related to the fMRI test-ing portion of the study. Table 2 presents background characteristics by depression

Table 1. Clinical impairment categories.

Impairment

Category (value) DescriptionNo. ofWomen

Not Impaired (0) EPDS less than 10, no clinical signs of impairment 33

Mild (1) non-continuous reduced energy, enjoyment, and focuswhen taking care of the baby or performing generaldaily tasks

10

Moderate (2) some persistent impairment in caring for the baby andin general daily functioning, difficulty organising timeand/or the presence of occasional suicidal ideation

9

Severe (3) persistent and continuous symptoms that interferedwith caring for the baby and performing general dailytasks, and/or the presence of persistent suicidalideation with or without plan

7

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group. Evaluated (PossDep) and non-evaluated women (NonDep) did not differ inage, parity, ethnicity, level of education, marital status and infant sex.

The two groups did differ on measures of psychological well-being, as presentedin Table 3. Women in the PossDep group showed significantly lower coping skills(EMQ) than NonDep women, [t(56) = 4.06, p < 0.01, (Cohen’s) d = 1.10]. Lowercoping skills were correlated with higher EPDS scores, [r(58) = –.52, p < 0.01].Taking antidepressant medication was associated with higher EPDS, [t(57) = –2.68,p < 0.01, d = –0.86] and lower coping skills [t(56) = 2.79, p < 0.01, d = 0.97].

Within-group analyses

Psychiatric evaluations of the 26 participants in the PossDep group revealed thatdiagnoses were heterogeneous, as shown in Table 3. EPDS score did not vary bydiagnosis [t(24) = 1.12, p = .27, d = 0.44]. Neither current enrolment in therapy[t(24) = –0.68, p = .50, d = –0.27] nor antidepressant medication [t(24) = –1.54,p = .14, d = –0.59] differed by whether or not the woman received a majordepression diagnosis. Postpartum onset was not associated with whether or notthe woman received a major depressive disorder diagnosis [t(24) = –1.30, p =.21, d = –0.53]. Women diagnosed with a major depressive disorder, however,presented with lower EMQ [t(24) = 2.33, p < .05, d = 0.91].

Diathesis, stress and resilience

The rates of occurrence of several potential diatheses and stressors are presented inTable 3. All participants in the PossDep group qualified for at least some degree ofdiathesis, a finding that supports the hypothesis that a diathesis is a necessary

Table 2. Demographic characteristics by depression group.

Characteristic (%) Non-depressed (NonDep) Possibly depressed (PossDep)

N 33 26Mean age (sd) 30.2 (± 4.2) 29.6 (± 5.7)Parity

Primiparous 12 (36.4) 14 (53.8)Multiparous 20 (60.6) 12 (46.2)Missing 1 (3.0) –

EthnicityCaucasian 28 (84.9) 21 (80.8)Asian 3 (9.1) 2 (7.7)Hispanic/Latino 1 (3.0) 1 (3.8)Other 1 (3.0) 1 (3.8)Missing/Not reported – 1 (3.8)

EducationHigh school 9 (27.3) 9 (34.6)College degree 13 (39.4) 12 (46.2)Post-graduate degree 11 (33.3) 5 (19.2)

Relationship statusSingle – 1 (3.8)Cohabitating 4 (12.1) 3 (11.5)Married 29 (87.9) 21 (80.8)Separated/divorced – 1 (3.8)

Female infant 18 (54.5) 11 (42.3)

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antecedent condition for the development of a disorder (Zuckerman, 1999). Someinformation was also gathered on the NonDep women via self-report questionnaire(Table 3). The following clinical formulations and brief case vignettes are used toillustrate our findings regarding diathesis, stress, and coping factors.

Vignette A: A 21-year old woman with adjustment disorder with mixed anxiety/depression, postpartum onset. Some non-specific diatheses and multiple psychoso-cial stresses combined with inadequate coping resources.

Participant was a primiparous, married woman. She reported no personal or familyhistory of mood disorders, but she had a positive family history of alcoholism. Shereported symptoms of irritability, emotional lability, onset insomnia, difficultyconcentrating, and persistent worry about stressors including finances and herrelationship to the infant’s father. She reported a normal pregnancy but was experi-encing psychosocial stress that had worsened since the birth of her child; both sheand her husband were unemployed, her husband was refusing to help withchildcare, and they were currently having relationship difficulties. She reportedlimited social support and feeling unprepared to be a mother. Interviewers providedinformation on local mothers’ support groups.

Vignette B: A 30-year-old participant with major depression with postpartum onsetin partial remission. Non-specific diathesis. Breastfeeding difficulty as a specificpostpartum psychosocial and physical stress. Average coping skills.

Table 3. Mood scale scores and mood-related factors by depression group.

FactorNon-depressed(NonDep)

Possibly depressed(PossDep)

Self-report questionnaires (± SD, range)EMQa⁄ 62.8 (12.6, 20–109) 51.4 (7.3, 36–64)EPDSb 4.5 (2.3, 1–9) 14.4 (3.7, 10–22)

Behavioral adjustments (%)Antidepressant medication 2 (6.1) 11 (42.3)Psychological therapy 1 (3.0) 9 (34.6)

Diagnoses (%)Major depressive disorder – 12 (46.2)Depressive disorder NOSc – 3 (11.5)Adjustment disorder – 6 (23.1)Anxiety disorder NOSc – 2 (7.7)Alcohol dependence – 1 (3.8)None – 2 (7.7)

Postpartum onset (%) – 21 (80.77)

Diatheses and Stressors (%)Family history of mood disorder – 20 (76.9)Family history of alcohol abuse 12 (36.4) 15 (57.7)Personal history of mood disorder – 19 (73.1)Major psychosocial stressord – 15 (57.7)Major physical birth trauma 1 (3.0) 4 (15.4)Breastfeeding difficulty – 9 (34.6)

Note: aExperience of Motherhood Questionnaire; bEdinburgh Postnatal Depression Scale; cNot otherwisespecified; dMajor psychosocial stress may include for example, extreme financial strain, partnershipdiscord, newborn with major long-term illness; ⁄p < 0.01.

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Participant was a primiparous, married woman. She reported no previous personalor family history of mood disorders, but did endorse a family history of alcoholism.She reported a normal pregnancy and long (27-hour) labour with no major birthcomplications. She experienced breastfeeding difficulties shortly after returninghome from the hospital. She felt like an ‘inadequate’ and ‘inept’ mother because ofthe breastfeeding difficulties and felt guilty about not wanting to feed her infantbecause of the pain. After seeking help from a lactation specialist and attending abreastfeeding support group, her mood improved but she continued to feel that shedid not have a ‘strong, intimate connection’ with her child and her depressivesymptoms worsened. With the urging and support of her husband, she was able touse behavioural activation techniques to slowly improve her mood. Interviewersencouraged her to continue to exercise and remain involved in community supportgroups.

Vignette C: A 31-year-old participant with adjustment disorder with anxiety, post-partum onset. Specific postpartum psychosocial and physical stress from serioushealth problems of baby and severe birth trauma. Marked diathesis for depressionbut strong social support and coping.

Participant was a primiparous, married woman. She reported a family history ofanxiety and depression and a personal history of depression that was treated withantidepressants. She experienced symptoms of increased anxiety, constant worry,frustration and guilt over opting to have a home birth. She felt overwhelmed, butremained able to find pleasure in daily activities. Although her pregnancy was notidentified as ‘high risk’, she delivered preterm, and on the day of delivery shelearned that she had had velamentous insertion of the placenta (i.e. a dangerouscondition wherein the veins of the baby ran across the placenta before comingtogether in the umbilical cord). Her baby was also born intrauterine growth-restricted and had polycythemia (i.e. overproduction of red blood cells possibly dueto low oxygen levels). Her child experienced several seizures as a newborn, had astroke three days after birth, and needed continued medical care with a possiblediagnosis of cerebral palsy. She reported to have a strong support network and mar-ital relationship. Interviewers recommended she speak with her physician about herantidepressant medication dosage level and provided information to find supportgroups for mothers with special needs children.

Functional impairment

Participants’ level of impairment was rated according to categories listed in Table 1.Impairment levels between those that received a major depressive disorder diagno-sis (mean = 2) and all other diagnoses (mean = 1.79) did not significantly differ,[χ2 (2, N = 26) = 2.60, p = .27], suggesting that therapeutic prevention and inter-vention is equally warranted for postpartum psychiatric diagnoses other than majordepressive disorder.

Discussion

In the current study, women were recruited 3–6 months postpartum. Women scoringhigh on the EPDS (PossDep) went on to participate in in-depth, semi-structuredpsychiatric evaluations. We found that PossDep women did not differ from NonDep

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women across a number of background factors including age, parity, ethnicbackground, level of education, marital status and infant sex. PossDep women,however, showed lower EMQ coping scores and were more likely to be takingantidepressant medication.

Psychiatric interviews allowed interviewers to complement the DSM-diagnosiswith a clinical formulation, which places the symptoms in the context of a narrativeof understanding and shows the interplay between diathesis, stress and coping skills/resources. Interviews revealed that serious postpartum disorder is not limited todepression. Many women (46%) were given diagnoses for which the DSM-IV-TRdoes not provide a postpartum onset specifier (American Psychiatric Association,2000) including depressive disorder NOS, adjustment disorder, anxiety disorderNOS and alcohol dependence. Those that did not show postpartum onset insteadreported onset of symptoms during pregnancy. They remained in analyses becausetheir symptoms became worse during the postpartum period and prenatal symptom-atology is a risk factor for postpartum onset disorder (Viguera, Tondo, & Koukopou-los, 2011). Additionally, two participants did not receive formal diagnoses despitetheir EPDS scores (10 and 12) suggesting that higher cut-off points may benecessary to determine if symptoms are at a clinical level. However, lower EPDSscores may reveal important signs of non-clinical levels of impairment (Magnusson,Lagerberg, & Sundelin, 2011). The variability in clinical presentation within thePossDep group suggests that, among women in the postpartum period, psychologicalsymptoms are distributed along a continuum rather than clustered in a few distinctdiagnostic categories. Findings of diagnostic heterogeneity support previous litera-ture showing that the EPDS does not precisely discriminate depression from otherpsychopathologies (Brouwers et al., 2001; Cox et al., 1987; Figueira et al., 2009;Gibson et al., 2009; Ji et al., 2011; Muzik et al., 2000; Rowe et al., 2008). Thus, theEPDS should be used together with other screening tools.

We also found that women experiencing postpartum depression were notnecessarily more impaired than those experiencing postpartum adjustment disorder.Coping skills, EPDS score, enrolment in therapy and antidepressant medicationwere also not dependent on specific diagnosis. Women experiencing any postpartumpsychopathology may also have a greater likelihood of breastfeeding difficulty, ashas been previously noted (Watkins, Meltzer-Brody, Zolnoun, & Stuebe, 2011;Zonana & Gorman, 2005). Mothers expressed that breastfeeding difficulties felt likea personal failure in their role as a mother (Koniak-Griffin, 1993). These findingsconfirm the limitations DSM diagnoses as sole indicators of impairment. Clinicalformulations, which summarise the elements of stress, diathesis and coping, can bevaluable for individualised treatment planning and providing rationale for discretetherapeutic suggestions about issues such as strengthening the marital relationship,increasing social support, stress management through exercise, and/or speaking withtheir physician about psychiatric medication adjustment.

The heterogeneity of the evaluated group may be understood from a diathesis–stress perspective (Hammen, 2005; Selye, 1974). Evidence from psychiatric evalua-tions suggested that psychopathology may have occurred when (a) the postpartumstress provoked a vulnerability for a mental disorder, (b) the amount and intensityof stress during delivery and postpartum was unusually high, and/or (c) past or cur-rent experiences contributed to chronic impairment of psychological health andresilience (Anda et al., 2006; Hammen, 2005; McEwen, 2008). It was found thatabout two-thirds of the PossDep women had family and personal histories of mood

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disorders. For these women, identifying the diatheses that put them at high risk forpostpartum pathology may be essential for early intervention. Changes in adaptiveregulatory systems due to the hormonal shifts that occur during labour and delivery(Weinstock & Cohen, 2003; Workman et al., 2012) may limit the resilience of amother who is vulnerable due to prior history. There were several frequently citedstressors, suggesting that the postpartum period presents a unique and intense stres-sor that may precipitate the appearance of a psychological condition. The findingthat women in the PossDep group showed lower EMQ coping scores than those inthe NonDep group confirms the importance of coping skills and resources indealing with postpartum stress. Because most women experience some degree ofemotional liability or ‘baby blues’ after delivery, the postpartum period may beconsidered inherently stressful for all women.

Important limitations in the current study include lack of follow-up and smallsample size. The limited sample size may have led to low statistical power to detecta significant difference between groups on factors such as infant sex (Lagerberg &Magnusson, 2012). Given the current findings, however, we have several recom-mendations for future research, prevention and intervention efforts. First, continuedresearch to better understand the dynamics of the postpartum period, as well asrelated psychopathologies and resilience factors, may benefit from a diathesis–stress–resilience perspective; understanding postpartum syndromes requires anuanced, dynamic perspective. Second, in agreement with previous research (Mat-they, Barnett, Howie, & Kavanagh, 2003), we suggest that limiting the applicationof a postpartum onset specifier is unsatisfactory (Brockington, 2011). From thecurrent results, the onset specifier should, at a minimum, be extended for use onanxiety (Matthey et al., 2003; Ross & McLean, 2006) and adjustment disorders.Allowing for the application of a postpartum onset specifier to additional diagnosticcategories is likely to assist in identifying a broader range of appropriate therapeuticinterventions and to facilitate a more accurate conceptualisation of postpartum disor-ders (Brockington, 2011; Sharma & Burt, 2011). Third, development of a broad,postpartum-relevant questionnaire that can capture different postpartum syndromesis needed for clinical and research use. Fourth, further research and development oftherapeutic interventions specific to postpartum women deserve to be promoted(Kleiman & Wenzel, 2011; Wenzel, 2011). Empirical testing of postpartum-specificinterventions would provide insight into factors contributing to postpartum disorders(O’Hara, Stuart, Gorman, & Wenzel, 2000). Clinical and non-clinical level interven-tion programmes may benefit from including components on breastfeeding supportand education (Watkins et al., 2011), parental education, support to achieve mater-nity role attainment (Hung, 2005; Koniak-Griffin, 1993; Mercer, 1985), and aspectsof couples therapy (Saurel-Cubizolles, Romito, Lelong, & Ancel, 2000). Early iden-tification of at-risk individuals and early intervention of modifiable risk factorswould also be beneficial (Howell, Mora, DiBonaventura, & Leventhal, 2009). Fifth,providing supportive programmes (e.g. paid maternity and paternity leave) beyondwhat is currently available in the US may provide a multitude of advantages to theat-risk mother as well as to her baby (Cheng, Fowles, & Walker, 2006).

AcknowledgementsThe current study was supported by grants from the National Institute of Mental Health(MH082925, PI: J. Heiman and H. Rupp) and (MH094011, PI: Q. Class). We would like tothank all women that participated as well as Christine White for recruitment assistance.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mentaldisorders (Vol. Revised 4th ed.). Washington, DC: American Psychiatric Association.

Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., et al.(2006). The enduring effects of abuse and related adverse experiences in childhood.European Archives of Psychiatry & Clinical Neuroscience, 256, 174–186.

Astbury, J. (1994). Making motherhood visible: The experience of motherhood question-naire. Journal of Reproductive and Infant Psychology, 12, 79–88.

Bagner, D. M., Pettit, J. W., Lewinsohn, P. M., & Seeley, J. R. (2010). Effect of maternaldepression on child behavior: A sensitive period? Journal of American Academy forchild and adolescent psychiatry, 49, 699–707.

Barrett, J., & Fleming, A. S. (2011). Annual research review: All mothers are not createdequal: neural and psychobiological perspectives on mothering and the importance ofindividual differences. Journal of Child Psychology and Psychiatry, 52, 368–397.

Brockington, I. (2011). Childbirth-onset specifiers for all psychiatric disorders. Archives ofWomen’s Mental Health, 14, 361.

Brouwers, E. P. M., Van Baarb, A. L., & Popc, V. J. M. (2001). Does the Edinburgh Postna-tal Depression Scale measure anxiety? Journal of Psychosomatic Research, 51, 659–663.

Brunton, P. J., & Russell, J. A. (2010). Endocrine induced changes in brain function duringpregnancy. Brain Research, 1364, 198–215.

Cheng, C., Fowles, E. R., & Walker, L. O. (2006). Postpartum maternal health care in theUnited States: A critical review. Journal of Perinatal Education, 15, 34–42.

Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression.Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journalof Psychiatry, 150, 782–786.

Diego, M. A., Field, T., Hernandez-Reif, M., Cullen, C., Schanberg, S., & Kuhn, C.(2004). Prepartum, postpartum, and chronic depression effects on newborns.Psychiatry, 67, 63–80.

Figueira, P., Correa, H., Malloy-Diniz, L., & Romano-Silva, M. A. (2009). EdinburghPostnatal Depression Scale for screening in the public health system. Revista de SaudePublica, 43, 79–84.

Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T.(2005). Perinatal depression: A systematic review of prevalence and incidence.Obstetrics and Gynecology, 106, 1071–1083.

Gibson, J., McKenzie-McHarg, K., Shakespeare, J., Price, J., & Gray, R. A. (2009). Asystematic review of studies validating the Edinburgh Postnatal Depression Scale inantepartum and postpartum women. Acta Psychiatrica Scandinavica, 119, 350–364.

Goodman, S. H. (2007). Depression in mothers. Annual Review of Clinical Psychology, 3,107–135.

Gutman, D. A., & Nemeroff, C. B. (2003). Persistent central nervous system effects of anadverse early environment: Clinical and preclinical studies. Physiology & Behavior, 79,471–478.

Hammen, C. (2005). Stress and depression. Annual Review of Clinical Psychology, 1,293–319.

Hankin, B. L., & Abela, J. R. Z. (Eds.). (2005). Development of psychopathology: A vulner-ability–stress perspective. Thousand Oaks, CA: Sage Publishing.

Howell, E. A., Mora, P. A., DiBonaventura, M. D., & Leventhal, H. (2009). Modifiablefactors associated with changes in postpartum depressive symptoms. Archives of Women’sMental Health, 12, 113–120.

Hung, C. (2005). Measuring postpartum stress. Journal of Advanced Nursing, 50, 417–424.Ji, S., Long, Q., Newport, D. J., Na, H., Knight, B., Zach, E. B., et al. (2011). Validity of

depression rating scales during pregnancy and the postpartum period: Impact of trimesterand parity. Journal of Psychiatric Research, 45, 213–219.

Kleiman, K., & Wenzel, A. (2011). Dropping the baby and other scary thoughts: Breakingthe cycle of unwanted thoughts in motherhood. New York, NY: Routledge.

Koniak-Griffin, D. (1993). Maternal role attainment. Journal of Nursing Scholarship, 25,257–262.

192 Q.A. Class et al.

Dow

nloa

ded

by [

Tex

as S

tate

Uni

vers

ity, S

an M

arco

s] a

t 08:

33 2

2 Se

ptem

ber

2013

Lagerberg, D., & Magnusson, M. (2012). Infant gender and postpartum sadness in the lightof region of birth and some other factors: A contribution to the knowledge of postpartumdepression. Archives of Women’s Mental Health, 15, 121–130.

Lazarus, R. (1984). Stress, appraisal, and coping. New York, NY: Springer.Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide

interventions in mental health? Using case formulation in clinical practice BioMedCentral Medicine, 10.

Magnusson, M., Lagerberg, D., & Sundelin, C. (2011). How can we identify vulnerablemothers who do not reach the cut off 12 points in EPDS? Journal of Child Health Care,15, 39–49.

Matthey, S., Barnett, B., Howie, P., & Kavanagh, D. J. (2003). Diagnosing postpartumdepression in mothers and fathers: Whatever happened to anxiety? Journal of AffectiveDisorders, 74, 139–147.

Mauri, M., Oppo, A., Montagnani, M.S., Borri, C., Banti, S., Camilleri, V., et al. (2010).Beyond ‘postpartum depressions’: Specific anxiety diagnoses during pregnancy predictdifferent outcomes. Results from PND-ReScU. Journal of Affective Disorders, 127,177–184.

McEwen, B. S. (2008). Central effects of stress hormones in health and disease: understand-ing the protective and damaging effects of stress and stress mediators. European Journalof Pharmacology, 583, 174–185.

Mercer, R. T. (1985). The process of maternal role attainment over the first year. NursingResearch, 34, 198–203.

Muzik, M., Klier, C. M., Rosenblum, K. L., Holzinger, A., Umek, W., & Katschnig, H.(2000). Are commonly used self-report inventories suitable for screening postpartumdepression and anxiety disorders? Acta Psychiatrica Scandinavica, 102, 71–73.

O’Hara, M. W., Stuart, S., Gorman, L. L., & Wenzel, A. (2000). Efficacy of interper-sonal psychotherapy for postpartum depression. Archives of General Psychiatry, 57,1039–1045.

Paulson, J. F., & Bazemore, S. D. (2010). Prenatal and postpartum depression in fathers andits association with maternal depression. Journal of the American Medical Association,303, 1961–1969.

Regier, D. A., Kaelber, C. T., Rae, D. S., Farmer, M. E., Knauper, B., Kessler, R. C., et al.(1998). Limitations of diagnostic criteria and assessment instruments for mental disor-ders. Implications for research and policy. Archives of General Psychiatry, 55, 109–115.

Ross, L. E., Evans, S. E. G., Sellers, E. M., & Romach, M. K. (2003). Measurement issuesin postpartum depression part 1: Anxiety as a feature of postpartum depression. Archivesof Women’s Mental Health, 6, 51–58.

Ross, L. E., & McLean, L. M. (2006). Anxiety disorders during pregnancy and the postpar-tum period: A systematic review. Journal of Clinical Psychiatry, 67, 1285–1298.

Rowe, H. J., Fishe, J. R. W., & Loh, W. M. (2008). The Edinburgh Postnatal DepressionScale detects but does not distinguish anxiety disorders from depression in mothers ofinfants. Archives of Women’s Mental Health, 11, 103–108.

Saurel-Cubizolles, M., Romito, P., Lelong, N., & Ancel, P. (2000). Women’s health afterchildbirth: A longitudinal study in France and Italy. British Journal of Obstetrics andGynaecology, 107, 1202–1209.

Selye, H. (1974). Stress without distress. Philadelphia, PA: Lippincott.Sharma, V., & Burt, V. K. (2011). DSM-V: Modifying the postpartum-onset specifier to

include hypomania. Archives of Women’s Mental Health, 14, 67–69.Skopen, N., McLaughlin, K. A., Zeenah, C. H., & Nelson, C. A. (2012). Alterations in

neural processing and psychopathology in children raised in institutions. Archives ofGeneral Psychiatry, 69, 1022–1030.

Viguera, A., Tondo, L., & Koukopoulos, A. E. (2011). Episodes of mood disorders in 2,252pregnancies and postpartum periods. American Journal of Psychiatry, 168, 1179–1185.

Watkins, S., Meltzer-Brody, S., Zolnoun, D., & Stuebe, A. (2011). Early breastfeedingexperiences and postpartum depression. Obstetrics and Gynecology, 118, 214–221.

Weinstock, L. S., & Cohen, L. S. (2003). Endogenous gonadal hormones in postpartumpsychiatric disorders. Arlington, VA: American Psychiatric Publishing, Inc.

Journal of Reproductive and Infant Psychology 193

Dow

nloa

ded

by [

Tex

as S

tate

Uni

vers

ity, S

an M

arco

s] a

t 08:

33 2

2 Se

ptem

ber

2013

Wenzel, A. (2011). Anxiety in childbearing women: Diagnosis and treatment. Washington,DC: APA Books.

Whiffen, V. E., & Gotlib, I. H. (1989). Infants of postpartum depressed mothers:Temperament and cognitive status. Journal of Abnormal Psychology, 98, 274–279.

Workman, J. L., Barha, C. K., & Galea, L. A. M. (2012). Endocrine substrates of cognitiveand affective changes during pregnancy and postpartum. Behavioral Neuroscience, 126,54–72.

Zonana, J., & Gorman, J. M. (2005). The neurobiology of postpartum depression. CNSSpectrums, 10, 792–799.

Zuckerman, M. (1999). Vulnerability to psychopathology: A biosocial model. Washington,DC: American Psychological Association.

194 Q.A. Class et al.

Dow

nloa

ded

by [

Tex

as S

tate

Uni

vers

ity, S

an M

arco

s] a

t 08:

33 2

2 Se

ptem

ber

2013