A

R

T

I

C

L

E

IMPACT OF MATERNAL DEPRESSION ON PREGNANCIES AND ON EARLY ATTACHMENT ´ BAJI, AND JANOS ´ ´ ESZTER LEFKOVICS, ILDIKO RIGO

Semmelweis University The relatively high prevalence and duration of depression in the prenatal and postpartum periods reinforce the need for better understanding of maternal depression. The purpose of this article is to explore the main effects of depression to pregnancies’ outcome and to early attachment reviewing research from the last decade and to find the best way to prevent the negative effects of maternal depression to infants. Recent studies have reported significant associations between maternal depression and several adverse obstetric, fetal, and neonatal outcomes. Antenatal depression has been associated with shorter gestation and lower birth weight, with consequences for infant development. A number of studies have demonstrated an association between prenatal depression and attachment difficulties, which seems to play an important mediating role in the development of further adverse outcomes for children. This review reveals some potential risks of untreated depression during the antenatal and postnatal periods, with possibly significant implications for practice and further research. Considering the high prevalence of depression, antenatal detection of depressive symptoms and intervention before childbirth has huge importance in prevention. Early interventions also may need to focus on mother–infant interactions as a key factor of later child development.

ABSTRACT:

La relativamente alta prevalencia y duraci´on de la depresi´on en el per´ıodo prenatal y posterior al parto refuerza la necesidad de una mejor comprensi´on de la depresi´on maternal. El prop´osito de este art´ıculo es explorar los efectos principales de la depresi´on en el resultado del embarazo y en la temprana afectividad, revisando investigaciones de la u´ ltima d´ecada, y encontrar la mejor manera de prevenir los efectos negativos de la depresi´on maternal sobre los infantes. Estudios recientes han reportado significativas asociaciones entre la depresi´on maternal y varios adversos resultados obst´etricos, fetales y neonatales. La depresi´on antenatal ha sido asociada con una gestaci´on m´as corta y m´as bajos pesos al momento del nacimiento con consecuencias para el desarrollo del infante. Varios estudios han demostrado que hay una asociaci´on entre la depresi´on prenatal y las dificultades de afectividad lo cual parece tener un rol mediador importante en el desarrollo de posteriores resultados adversos para los ni˜nos. Esta revisi´on revela algunos riesgos potenciales de la no tratada depresi´on durante el per´ıodo antenatal y el postnatal, con posibles implicaciones significativas para la pr´actica y la futura investigaci´on. Considerando la alta prevalencia de la depresi´on, la detecci´on antenatal de los s´ıntomas depresivos y la intervenci´on antes del nacimiento del ni˜no tiene una importancia enorme en cuanto a la prevenci´on. Las tempranas intervenciones pudieran necesitar enfocarse tambi´en en las interacciones entre madre e infante como un factor clave del posterior desarrollo del ni˜no.

RESUMEN:

´ ´ RESUM E:

La pr´evalence relativement e´ lev´ee et la dur´ee de la d´epression dans la p´eriode pr´enatale et postpartum renforce le besoin qu’il y a de mieux comprendre la d´epression maternelle. Le but de cet article est d’explorer les effets principaux de la d´epression sur le r´esultat de grossesse et sur l’attachement pr´ecoce en passant en revue les recherches de ces dix derni`eres ann´ees et de trouver la meilleure fac¸on de pr´evenir les effets n´egatifs de la d´epression maternelle sur les b´eb´es. Des e´ tudes r´ecentes ont fait e´ tat de liens importants entre la d´epression maternelle et plusieurs mauvais r´esultats en mati`ere d’obst´etrique ou de sant´e fo´etale et n´eonatale. La d´epression avant la naissance a e´ t´e li´ee a` une gestation moins longue et un poids a` la naissance moins e´ lev´e avec des cons´equences sur le d´eveloppement du b´eb´e. Un bon nombre d’´etudes ont d´emontr´e un lien entre la d´epression pr´enatale et les difficult´es d’attachement, ce qui semble jouer un rˆole de m´ediation important dans le d´eveloppement de mauvais r´esultats a` venir pour les enfants. Ce compte-rendu r´ev`ele des risques potentiels si la d´epression n’est pas trait´ee dans la p´eriode avant la naissance ou apr`es la naissance, avec peut-ˆetre des implications importantes pour la pratique et des recherches suppl´ementaires. Si l’on tient compte de la grande pr´evalence de la d´epression, la d´etection de symptˆomes d´epressifs avant la naissance a une importance e´ norme dans la pr´evention. Les interventions pr´ecoces doivent peut-ˆetre aussi se focaliser sur les interactions m`ere-b´eb´e en tant que facteur cl´e du d´eveloppement a` venir de l’enfant. Die relativ hohe Pr¨avalenz und Dauer der Depression in der pr¨a-und postpartalen Phase bekr¨aftigen die Notwendigkeit f¨ur ein besseres Verst¨andnis der m¨utterlichen Depression. Das Ziel dieses Artikels ist es, die wichtigsten Auswirkungen der Depression auf den Schwangerschaftsausgang und auf die fr¨uhe Bindung mittels eines Reviews zu den Forschungen der letzten zehn Jahre zu untersuchen und den

ZUSAMMENFASSUNG:

Direct correspondence to: Eszter Lefkovics, Semmelweis University, 1st Department of Obstetrics and Gynecology, Baross utca 27. 1085, Budapest, Hungary; e-mail: [email protected]. INFANT MENTAL HEALTH JOURNAL, Vol. 35(4), 354–365 (2014)  C 2014 Michigan Association for Infant Mental Health View this article online at wileyonlinelibrary.com. DOI: 10.1002/imhj.21450

354

Effects of Maternal Depression on Infants and Attachment



355

besten Weg zu finden, negative Auswirkungen der m¨utterlichen Depression auf ihre S¨auglinge zu verhindern. J¨ungste Studien haben signifikante Assoziationen zwischen m¨utterlichen Depressionen und verschiedenen negativen gyn¨akologischen, fetalen und neonatalen Ergebnissen berichtet. Pr¨anatale Depression wurde mit k¨urzeren Schwangerschaften und niedrigerem Geburtsgewicht mit entsprechenden Folgen f¨ur die Entwicklung des Kindes in Verbindung gebracht. Eine Reihe von Studien haben einen Zusammenhang zwischen pr¨anataler Depression und Bindungsschwierigkeiten gezeigt, welche eine wichtige Mediatorrolle in der Entwicklung von weiteren negativen Ergebnissen auf Seiten der Kinder einzunehmen scheinen. Dieses Review deckt einige potentielle Risiken von unbehandelten Depressionen w¨ahrend der pr¨a-und postnatalen Phase auf, die auf m¨oglicherweise bedeutsame Implikationen f¨ur die Praxis und die weitere Forschung verweisen. In Anbetracht der hohen Pr¨avalenz der Depression sind die vorgeburtliche Erkennung von depressiven Symptomen und die Intervention vor der Geburt von großer Bedeutung in der Pr¨avention. Fr¨uhe Interventionen sollten auch auf Mutter-Kind-Interaktionen fokussieren, die als ein Schl¨usselfaktor f¨ur die sp¨atere Entwicklung des Kindes gelten. ABSTRACT: The relatively high prevalence and duration of depression in the prenatal and postpartum period reinforce the need for better understanding of maternal depression. The purpose of this article is to explore the main effects of depression to pregnancies outcome and to early attachment reviewing researches from the last decade and to find the best way to prevent the negative effects of maternal depression to infants. d d:d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d10d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d dddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddd ddddddddddddddddddddddddddddddddddddddddddddddddddddddd ddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddd

* * * INTRODUCTION Perinatal Depression

Depression is common in women, and the puerperium is a time of particular vulnerability (Marcus, 2009). The perinatal period may increase the risk of depressive episodes. Depression during this period can lead to long-term consequences, not only for the women experiencing it but also for the children and family (Gaynes, 2005). Depression related to childbearing can occur during pregnancy (antenatal depression), after birth (postnatal depression), or both. Antenatal and postnatal depression share approximately similar prevalence ratings to those for depression in the general population, with estimates ranging from 12 to 20% (Bennett, Einarson, Taddio, Koren, & Einarson, 2004; Dennis, Heaman, & Vigod, 2012; Gavin et al., 2005). Antenatal depression encompasses major and minor depressive episodes beginning during pregnancy. Undiagnosed depression during pregnancy is the leading risk factor for postpartum depression (Leigh & Milgrom, 2008; Robertson, Grace, Wallington, & Stewart, 2004), in which symptoms can occur immediately after birth and up to 1 year after delivery. Postnatal depression can be associated with poor maternal– infant attachment and may have adverse effects on infant further development. Despite these findings, depressive disorders continue to be undetected and undertreated in pregnancy (Kelly, Russo, & Katon,

2011), as common symptoms (sleep, energy, and appetite change) may be misinterpreted as normative experiences of pregnancy. The main symptoms include depressed mood, feelings of helplessness and hopelessness, feelings of guilt and worthlessness, loss of energy, and problems with sleep and appetite. Another important reason of the ambush of symptoms is that having postnatal depression is a shameful thing for many women, bearing the stigma of a mental illness. The shame is greatly compounded by the fact that the mother may feel guilty because she cannot enjoy her child as much as she expected to. Therefore, measurement of the prevalence of depression during pregnancy and of its impact on pregnancy outcomes is difficult. Risk Factors of Perinatal Depression

There is evidence that a number of risk factors are associated with maternal depression. Women experiencing these risk factors should be watched carefully by providers and screened regularly during pregnancy and postpartum. Significant predictors for antenatal depression are low self-esteem, antenatal anxiety, low social support, negative cognitive style, major life events, low income, and history of abuse (Leigh & Milgrom, 2008). According to a synthesis of literature (Robertson et al., 2004), the strongest predictors of postpartum depression are depression during pregnancy, anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, low levels of social support,

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

356



E. Lefkovics, I. Baji, and J. Rig´o

and a previous history of depression. Moderate predictors of postpartum depression are childcare stress, low self-esteem, maternal neuroticism, and difficult infant temperament. Small predictors include obstetric and pregnancy complications, negative cognitive attributions, single marital status, poor relationship with partner, and lower socioeconomic status including income. No relationship was found for ethnicity, maternal age, level of education, parity, or gender of child. The most serious risk factor for maternal depression is a previous episode of prenatal or postpartum depression. Approximately 50 to 62% of women with a history of postpartum depression and 33% of women with a history of perinatal depression will experience depression during or after a next pregnancy (National Business Group of Health, 2005). Soderquist, Wijma, Thorbert, & Wijma (2009) assessed the risk factors for postpartum depression and posttraumatic stress disorder (PTSD) during pregnancy. They found that 1.3% of the women who participated in their study met Diagnostic and Statistical Manuel of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000) criteria for a diagnosis of PTSD. The study found that women with PTSD or postpartum depression have risk factors that are very similar. Another study by Ayers & Pickering, (2001) found that 6.9% of women met criteria for PTSD or postpartum depression. Nearly 3% of those women had not met criteria for PTSD or depression prior to delivery. PTSD can compound and complicate the postpartum depression (Lefkowitz, Baxt, & Evans, 2010). Risk Mechanism of Maternal Depression

Maternal depressive symptoms may affect child development even before birth via alterations of the intrauterine environment. Depressive symptoms in the prenatal period are linked to alterations in the stress response and immune systems of the fetus. It is hypothesized that depression results in neuroendocrine alterations, including the hyper- or hypoactivity of the hypo–thalamic–pituitary (HPA) axis (Li, Liu, & Odouli, 2009). The hormonal end products of the HPA axis, such as cortisol and norepinephrin, may in turn affect uterine artery blood flow, fetal development growth, and parturition. Maternal anxiety during pregnancy also was associated with reduced urinary artery blood flow during the third trimester of pregnancy, which may interfere with the transmission of nutrients from the mother to the fetus (Mulder et al., 2002). Maternal depression also may indirectly affect perinatal health outcomes through mediation by maternal risk behaviors such as substance abuse (Gilman & Abraham, 2001) and may decrease their compliance with prenatal care, putting themselves and their babies at risk for complications and poor birth outcomes. Maternal depression threatens a mother’s emotional and physical ability to care for and foster a healthy relationship with her child, so another way in which risk can be transmitted is inadequate parenting (Forman et al., 2007). Depressed mothers may lack the responsive parenting known to be necessary for infants’ healthy attachment relationships (Goodman & Brand, 2009). In

addition to lack of responsiveness, researchers have revealed that maternal depression can be associated with a pattern of withdrawn, unresponsive interaction or hostile, intrusive overstimulation (Goodman & Brand, 2009). Depressed mothers’ inadequate parenting has implications for infants’ adaptation and further development. These mechanisms may have important roles in the transmission of depressive symptoms to the infant. Maternal Depression Impacts the Mother–Child Relationship

Bowlby’s (1982) attachment theory is based on the idea that the early relationship that develops between the infant and caregiver provides the foundation for later development. Infants develop distinct attachment patterns with their caregivers based on the caregiver’s sensitivity and emotional availability during times of distress, during which the infant’s attachment system is activated, and he or she is likely to display a variety of hard-wired attachment behaviors that are meant to clearly signal to the caregiver the need for soothing (Ainsworth, 1979). Winnicott (1987) introduced the idea of “primary maternal preoccupation,” which is the mother’s attitude of empathy with the child that allows her to understand and fulfill the infant’s needs. An infant is typically in tune with the emotional signals in his or mother’s voice, gestures, movements, and facial expressions. Later empirical findings (e.g., Tronick & Reck, 2009) have highlighted the impact of maternal depression on the infant affective state and on the capacity for repairing states of miscoordination. The impact is manifested not only in severely and acutely depressed mothers but in mothers who have only high levels of depressive symptoms. These infants develop negative affective states that bias their interactions with others and exacerbate their affective problems. Parental responsiveness plays a crucial role in parent–infant interaction, as primary caregivers are the critical external factor shaping the development of effective biological and emotional systems (Waxler, Thelen, & Muzik, 2011). Women with postpartum depression tend to question their ability to form a secure bonding with their newborn (Barnes, 2006); however, their doubt does not necessarily lead to attachment problems (Kumar, 1997). The interaction disturbances of depressed mothers and their infants appear to be universal, across different cultures and socioeconomic status groups, and include less sensitivity of the mothers and responsivity of the infants (Parsons, Young, Rochat, Kringelbach, & Stein, 2012). Several caregiving activities also appear to be compromised by postpartum depression, such as feeding practices (most especially breastfeeding), sleep routines, and wellchild visits, vaccinations, and safety practices (Field, 2010). Infants might be particularly sensitive to environmental influances during the early postnatal period because they are dependent on care from others (Moehler, Brunner, Wiebel, Reck, & Resch, 2006). Presence of maternal depressive symptoms during a child’s first year of life increases the risk of adverse child outcomes (Bagner, Pettit, Lewinsohn, & Seeley, 2010). This article reviews the main effects of maternal depression on the infant based on research from the last decade. Based on

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Effects of Maternal Depression on Infants and Attachment

the results, our aim is to find the best time and the most effective method to prevent adverse consequences on an infant’s development. METHODS

In conducting this systematic review, standard electronic databases were used, including MEDLINE, PubMed, and PLOS One. Articles also were gathered from the references of papers generated by the initial search. These studies had to report on original data, be in English, and be published from January 2003 through January 2013. Keywords were the combination of the following terms: “prenatal,” “postnatal,” “maternal,” “depression,” “pregnancy,” and “attachment.” Screening Tools Usaed to Measure Depression in the Studies

Common self-report instruments used to screen depressive symptoms include the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977)) and the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987). In 31% of the reviewed studies, the EPDS was used to detect depression. The EPDS is considered as a sensitive (96%), but only moderately specific (82%), screening tool for postpartum depression (Murray & Carothers, 1990). Total scale scores range from 0 to 30, cutoff scores ranged from 9 to 13 points in the reviewed studies. This scale is more specific to the perinatal period and less reliant on somatic symptoms (e.g., sleep and appetite dysregulation) which are normative in pregnancy. In a recent review (Gjerdingen, & Yawn, (2007)), the EPDS was the most extensively researched postpartum measure, with the limitation that this scale is better at identifying depressed postnatal women with anhedonic and anxious symptomatology rather than those whose depression presents mainly with psychomotor retardation (Guedeney, Fermanian, Guelfi, & Kumar, 2000). The CES-D was used in 24% of the reviewed studiees. The 20-item scale asks participants to respond to questions assessing the verbal/cognitive and affective dimensions of depression on a Likert scale of 0 (low) to 3 (high). Subjects respond to questions such as “I could not get going” and “I felt sad” in relation to how they felt in the previous week. Some researchers have used the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) or the Patient Health Questionnaire Hospital Anxiety and Depression Rating Scale (HADS; Zigmond & Snaith, 1983). The HRSD is a multiple-item questionnaire used to provide an indication of depression. The HADS is commonly used to determine the levels of anxiety and depression that a patient is experiencing. The HADS is a 14-item scale that generates ordinal data. Seven of the items relate to anxiety, and seven relate to depression. The Pregnancy Related Anxiety Questionnaire (PRAQR; Kroenke, Spitzer, Williams, & Lowe, 2009) or the State-Trait Anxiety Inventory (STAI) were used to assess anxiety. The PRAQR focuses on specific fears related to pregnancy (e.g., fear of giving birth, fear of bearing a handicapped child, and concern about one’s appearance). The STAI is comprised of 20 items and assesses the



357

intensity of anxiety symptoms. The scores range from 20 to 90 with higher scores correlating with greater anxiety. The cutoff for high anxiety is 48. Research has demonstrated that the STAI has adequate concurrent validity and internal consistency (Spielberger, Gorsuch, & Lushene, 1970), and the scale has been used in several studies with pregnant women (e.g., Da Costa, Larouche, Drista, & Brender, 2000). The aforementioned scales seem to be popular for measuring depressive symptoms during pregnancy, although they do not allow for a clinical diagnosis of depression. Thus, 19% of the studies examined for our study had used the Structured Clinical Interview for Depression (SCID; Spitzer, Williams, Gibbon, & First, 1992), which is a semistructured instrument administered by researchers trained in its use. The output of the SCID is recorded as the presence or absence of each of the disorders being considered, for current episode and for lifetime occurrence, and is considered the “gold standard” for the research diagnosis of depression (Marcus, 2009). RESULTS

This article aimed to review the results of studies from the last decade, focusing on the consequences of prenatal depression to pregnancy outcome and on the impact of postnatal depression to attachment security. Therefore, the review is divided into two sections. The first section reviews the evidence on the impact of prenatal depression on pregnancy outcome. In this section, 27 articles were suitable to previous conditions. The second section examines maternal depression effects on early child development, focusing on mother–infant attachment as a potential mediator. In the second section, 35 articles were analyzed. Effects of Antenatal Depression on Pregnancy Outcome

Recent studies have reported significant associations between prenatal depression and several adverse obstetric, fetal, and neonatal outcomes (Alder, Fink, Bitzer, H¨osli, & Holzgreve, 2007). Complications of pregnancy associated with depression include preterm birth (Dayan et al., 2002; Dayan et al., 2006; Li et al., 2009; Orr, James, & Blackmore, 2002), restricted fetal growth (Diego et al., 2009), and preeclampsia (Kurki, Hiilesmaa, Raitasalo, Mattila, & Ylikorkala, 2000; Wallis, & Saftlas, 2009). Studies have demonstrated that perceived life-event stress as well as depression and anxiety predicted lower birth weight, decreased Apgar scores, and smaller head circumference (e.g., Marcus, 2009). Andersson, Sundstr¨om-Poromaa, Wulff, Astr¨om, & Bixo, (2004b) found an association between antenatal depressive and/or anxiety disorders and increased healthcare use (including cesarean deliveries) during pregnancy and delivery. At the same time, results of different studies have not been congruent in every case. Variable prevalence rates of prenatal depression and obstetric complications noted within the scientific literature reflect the variety of screening instruments used and whether they reflect data collected by self-report or trained

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

358



E. Lefkovics, I. Baji, and J. Rig´o

researchers. In addition, timing of the data collection relative to the duration of pregnancy lends itself to variable prevalence rates. Another influencing factor is the different sample size used in the various studies. According to Alder et al. (2007), the two most explicit pregnancy outcomes of antenatal depression are low birth weight and preterm delivery. Low fetal birth weight. Fetal growth restriction is among the leading causes of fetal morbidity and mortality and has been associated with adverse long-term health outcomes. Inasmuch as early diagnosis of fetuses at risk for fetal growth restriction can reduce perinatal morbidity and mortality, it is important to identify factors that place fetuses at risk for fetal growth restriction (Diego et al., 2009). Many studies have examined the effects of depression, anxiety, and/or stress on birth weight and infant growth. Recent studies (Bahri, Hosseinian, Afrooz, & Hooman, 2011; Diego et al., 2006; Field et al., 2009; Goedhart et al., 2010; Li et al., 2009; Rahman, Bunn, Lovel, & Creed, 2007; Rondo et al., 2003; Van Dijk, Van Eijsden, Stronks, Gemke, & Vrijkotte, 2010) have found that women who exhibit elevated depression symptoms during pregnancy are at increased risk for delivering premature and low birth weight infants. Researchers have suggested that high prenatal cortisol levels associated with depression may result in elevated fetal cortisol, delayed fetal growth, and prematurity (Field, 2010). Prenatal maternal-distress effects on the fetus appear to be mediated by maternal neuroendocrine function. This is consistent with previous research (Field et al., 2006) documenting that neonates in a high-cortisol group had lower gestational ages and a lower birth weights. Fetuses of depressed women exhibit lower estimated fetal weights during midgestation and lower birth weights than do fetuses of nondepressed women (Diego et al., 2009). In a recent study, Field (2010) found that comorbidity of clinical level of depression and of anxiety led to a significantly greater incidence of prematurity. Preterm delivery. Preterm delivery, defined as delivery at less than 37 completed weeks of gestation, is the leading cause of infant mortality and morbidity as well as medical expenditures for the infants. Psychopathological factors have emerged as potentially important risk factors for preterm delivery (Alder et al., 2007). Many researchers (Kim et al., 2008; Nicholson et al., 2006; Rondo et al., 2003; Straub et al., 2012; Van Dijk et al., 2010) have described the association between depressive symptoms and an increased risk of preterm birth. Some have emphasized the role of psychological factors such as self-perceived distress (Martini, Knappe, BeesdoBaum, Lieb, R, & Wittchen, 2010) and a lower level of maternal self-esteem (Bodecs et al., 2011) in association with preterm delivery. Nicholson et al., (2006) emphasized the intermediate role of health-related quality of life. Recent studies have demonstrated that mood disorders, especially depression during pregnancy, may influence the levels of placental hormones and placental functions (Diego et al., 2006; Neggers, Goldenberg, Cliver, & Hauth, 2006), which play a

central role in maintaining a healthy pregnancy. These results have been supported by those in other studies (Diego et al., 2009; Field et al., 2009), which suggest that maternal depression may lead to adverse perinatal outcomes via increased prenatal maternal cortisol levels. Prenatal maternal cortisol levels appear to play a role in mediating the variance in gestational age at birth. The earliest findings (Mancuso, Schetter, Rini, Roesch, & Hobel, 2004) have supported the mediation hypothesis indicating that women with high corticotropin-releasing hormone (CRH) levels and high maternal prenatal anxiety at 28 to 30 weeks’ gestation delivered earlier than did women with lower CRH levels and maternal prenatal anxiety. The risk of preterm delivery increases with the severity of depressive symptoms, demonstrating a dose–response relationship between depressive symptoms and the risk of preterm delivery (Li, et al., 2009). On the other hand, findings concerning the effect of antenatal depression and anxiety on neonatal outcomes have been controversial. More studies (Andersson, Sundstr¨om-Poromaa, Wulff, Astr¨oom, & Bixo, 2004a; Berle et al., 2005; Bodecs et al., 2011; Goedhart et al., 2010; Larsson, Sydsj¨o, & Josefsson, 2004) have not found any differences in spontaneous preterm birth between infants of mothers with depression or anxiety and those of healthy controls. Qiao Wang, Li, & Wang, (2012) found that antenatal depressive and/or anxiety symptoms during pregnancy can even increase the risk of prolonged pregnancy. Contradictions between the different results can be explained by methodological problems. The assessment of depression and anxiety was made in different trimesters of pregnancy by different self-assessment questionnaires. Effects of Postnatal Depression to the Mother–Infant Relationship and Early Infant Development

Kingston, Tough, & Whitfield (2012) suggested that prenatal distress can have an adverse effect on cognitive, behavioral, and psychomotor development, and that postpartum distress also contributes to cognitive and socioemotional development. Other researchers also have noted that children of depressed mothers are at increased risk for impaired functioning across cognitive, social, and academic functioning as well as poor physical health (Cummings & Kouros, 2009; Deave, Heron, Evans, & Emond, 2008; Righetti-Veltema, Conne-Perr´eard, Bousquet, & Manzano, 2002). A child’s cognitive and language development during the newborn period are affected by mothers’ use of positive affect, infant-directed speech, affectionate touch (Feldman, Eidelman, & Rotenberg, 2004), and materal responsiveness (Milgrom, Westley, & Gemmill, 2004), which has an important mediating role. Depressed and nondepressed mothers’ interactions seem to vary qualitatively across these domains, variations that may systematically influence children’s interest in communication and learning about their environments (Sohr-Preston & Scaramella, 2006). Because depressive symptoms distort thinking and impair judgment, being depressed interferes with a mother’s capacity to attune herself to the needs of her infant and affects the sensitivity of her responsiveness (Bansil et al., 2010), which might impact on

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Effects of Maternal Depression on Infants and Attachment

parenting sensitivity and therefore affect the vulnerability of children. Hostile or withdrawn parenting has been linked to patterns of child brain activity associated with anxious and withdrawn emotions, which may persist over time (Diego et al., 2009). The importance of synchronization between infant and caregiver also has been emphasized (Guedeney, 2007). The withdrawn social behavior of infants to the clinician was found to be related to the mother’s report of whether she had felt more irritable, sad, anxious, or depressed since the birth (Matthey, Guedeney, Starakis, & Barnett, 2005). Implications of maternal depression to early attachment. One of the strongest risk factors of postpartum depression is a history of maternal depressive disorder (MMD), so more studies have focused on its effect on attachment. Clinically defined MDD during pregnancy negatively impacts maternal–fetal bonding (McFarland et al., 2011), suggesting that the basis for poor mother-to-infant attachment in postpartum MDD may have roots in pregnancy. Feelings of inadequacy, negative cognitions, and self-doubt influence the attachment model of depressive mothers (Hornstein et al., 2006). It has been proposed that increased depressive symptoms in the peripartum period may negatively impact women’s internal attachment model and view of relationships (Noorlander, Bergink, & van den Berg, 2008; Scharfe 2007), and may effect lower emotional bonding to infants 2 o 3 months’ postpartum (Edhborg, 2011; Nagata, 2003; Rogosh, 2004). Within attachment theory, syncronization plays an important role. Guedeney et al. (2011) underlined the importance of synchronization between infant and caregiver, and highlighted the key concept of attachment disorganization and its relationship with sustained social withdrawal as a defense mechanism and an alarm signal when synchronization fails (Guedeney, 2011). Negative thinking interferes with the carer’s communications by altering attentional focus and reducing the carer’s responsiveness to the environment. Thus, the carer’s ability to respond sensitively to infant cues and needs is reduced (Beebe, 2008; Field et al., 2007; Murray, 2010; Robbins Broth, 2004; Stein, 2012). Depressed mother–infant dyads present less vocal and visual communications, less corporal interactions, and less smiling at the infant age of 3 months (Righetti-Veltema et al., 2002), and the negative interactional effects last 15 months later, with an insecure attachment style (Righetti-Veltema, Bousquet, & Manzano, 2003). Depressed mothers rate their infants as more temperamentally difficult, as compared with ratings of healthy mothers, even when controlling for a history of maternal prenatal stress or psychopathology, and maternal ratings of the amplitude of infant negative affect are associated with maternal depression severity (McGrath, 2007; Tikotzky, 2010). In general, the parenting of depressed mothers has been described as either hostile (increased negative behaviors) or withdrawn (decreased positive behaviors) (Aceti et al., 2012; LyonsRuth, 2002), and this may adversely affect the attachment process. Maternal depression at 2 months predicted insecure infant attachment, but high disengagement or intrusion uniquely predicted



359

disorganized attachment (Tomlinson, 2005). Tronick & Reck (2009) assumed that depressed mothers have problems interpreting their infants’ affective communication. Tronick & Reck (2009) also found that depressed mothers can be divided into different groups: One type consists of “intrusive” angry mothers who handle their children rather roughly. The disengaged, unresponsive, and withdrawn mothers represent another subtype. It can be assumed that infants of hostile, intrusive mothers have to cope with different interactional problems than do infants of disengaged mothers. Research has suggested that infants of withdrawn mothers must have learned that their behavior has only a minimal effect on their mothers’ behavior, leading to mutual withdrawal from interaction. Infants of intrusive depressed mothers have repetitively experienced negative reactions, which fuels mutually coercive interaction patterns (Field, 1992). Potential consequences of these types of attachment patterns may be the development of internalizing problems in early childhood and later depression (Hayes, Goodman, & Carlson, 2012; McMahon, 2005). At the same time, recent studies have not found that depression limited to the postnatal period has a direct, long-term impact on child attachment and further developmental trajectories (Tharner et al., 2012; Wan, 2009). Furthermore, a history of MDD, regardless of severity or psychiatric comorbidity, was not associated with an increased risk of infant attachment insecurity or disorganization according to a Dutch cohort study (Tharner et al., 2012). A possible explanation for the absence of the association between maternal depressive symptoms and attachment quality can be the chronicity of depression, which can be a consequence of using self-report measures. Importance of the chronicity of symptoms was supported by McMahon’s (2006) study in which persistent depression measured at 12 months was associated with insecure attachment, and raised the risk to both insecure and disorganised attachment at 3 years (Campbell, 2004). Earlier research by Murray (1992) has supported the complexity of the relationship between postnatal depression and its effects; he found that postnatal depression had no effect on general cognitive and language development, but appeared to make infants more vulnerable to adverse effects of lower social class and male gender. Considering maternal depression as a risk factor of inadequate attachment, it is important to identify the potential protective factors. Protective factors to prevent negative attachment effects. Parenting quality can moderate the association between depression and infant outcome, according to the latest results summarized in the following section. Exposure to higher levels of maternal depressive symptoms during pregnancy was associated only with higher rates of infant disorganized attachment when maternal parenting at 3 months was less optimal (Hayes et al., 2012). Maternal sensitivity moderated the effect of major depressive disorder on the social engagement of children at 9 months (Feldman et al., 2009). These findings have suggested that enhancing maternal parenting behaviors during this early period in development has the potential to alter pathways to disorganized attachment among infants exposed

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

360



E. Lefkovics, I. Baji, and J. Rig´o

Path diagram of mediation hypothesis

Antenatal depression

Postnatal depression

Depressive symptoms

Depressive symptoms Feeling of inadequacy, negative cognitions, self-doubt

Infant development Early attachment Reduced maternal sensitivity and responsitivity

Pregnancy complications

Protective factors

Preterm birth, restricted fetal and birth weight, preeclampsia

Sensitive responsivness, maternal attachment state of mind, partner support FIGURE 1.

Cognitive, psychomotor, and behavioral development

Path diagram of the mediation hypothesis.

to antenatal maternal depressive symptoms. A recent study has found that secure attachment had a protective power against the in utero effects of maternal depression and an elevated stress cortisol level (Forman et al., 2007). Sensitive responsivness, the ability to respond appropriately to the child’s attachment needs, has been shown to be the most reliable predictor of a secure attachment relationship (McElwain, 2006). The maternal working models of early loving relationships are emphasized (Tharner et al., 2012; Toth, Rogosch, Sturge-Apple, & Cicchetti, 2009) as potentially moderating factors to protect against the effect of maternal depressive symptoms on the child. The relationship between maternal depression and child attachment also can be moderated by maternal attachment state of mind regarding attachment (McMahon, 2006). Maternal attachment state of mind may interact with the chronicity of depression, as insecure mothers were seven times more likely to report persistent depression (McMahon, 2006). Another protective factor can be partner support, which can mediate the effects of mothers’ interpersonal security and relationship satisfaction on maternal and infant outcomes. Supportive relationships may enhance feelings of well-being, personal control, and positive affect, thereby helping women to perceive pregnancy-related changes as less stressful. A meta-analysis by Beck (2001) has suggested that a low level of social support is one of the strongest predictors of PPD. Social support conceptualized and measured in different ways has been found to positively influence the mothering experience, enhancing self-efficacy in the postpartum period (Haslam, Pakenham, & Smith, 2006; LeahyWarren, McCarthy, & Corcoran, 2012). A high-quality, supportive partner relationship during pregnancy may contribute to improved maternal and infant well-being postpartum, indicating a potential role for partner relationships in mental health interventions, with possible benefits for infants as well (Stapleton et al., 2012; Tharner et al., 2012).

DISCUSSION

Most of the reviewed studies supported the association of psychological factors with both adverse pregnancy outcome and negative effects to early attachment. Available research has suggested that depression is one of the most common complications of pregnancy. At the same time, evidence of negative effects on attachment is not clear-cut. The degree of symptom severity, chronicity of depression, and mother’s pattern of behavior is likely to influence the quality of attachment. To prevent the possible adverse outcomes of maternal depression, recognizing the potential protective factors has a key role. Recent studies have supported the importance of protective factors such as parenting quality, sensitive responsiveness, maternal state of mind, and partner’s support. Contradictions in the findings are due to differences in the scales used to evaluate depression, sample size, and insufficient control of important limiting factors for evaluating the results. Many of these studies have the limitation of using self-report measures to assess parental depression; therefore, results are based largely on these studies of symptomatology, not investigations of confirmed diagnoses. More longitudinal studies of confirmed diagnoses would be helpful, particularly with larger samples, to elucidate the association between depression and its consequences. The prevalence of pre- and postpartum depression and their longterm effects on developing children illustrate the need for further research in this area.

Implications for Future Programs

The findings from the reviewed studies on early interaction problems have important clinical implications for pediatric healthcare professionals. One of the implications is the need for universal screening of maternal depression during the antenatal and the postpartum periods. Pediatricians are being encouraged to provide

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Effects of Maternal Depression on Infants and Attachment

anticipatory guidance to mothers with depression symptoms through implementation of universal postpartum depression screening during well-child visits. This review highlights the protective function of the child– mother attachment relationship during early infancy. Based on this result, another important implication is that reducing mothers’ depressive symptoms alone does not necessarily lead to improvements in parenting and children’s development (Forman et al., 2007). Early interventions also may need to focus on mother–infant interactions. Treatment that focuses on mother–infant attachment could be especially beneficial for mothers with postpartum depression (Forman et al., 2007; Noorlander et al., 2008). A few studies, of variable quality, have explored the impact of interventions such as home visiting, telephone counseling, interactive coaching, group interventions, and massage therapy. The results of these studies are still very preliminary and must be interpreted with caution. Large, well-controlled longitudinal studies that specifically measure maternal–infant relations and child development are required. A meta-analysis conducted by Bakermans-Kranenburg, van IJzendoorn and Juffer (2003), in which they concluded that interventions which target parental sensitivity and which are initiated after approximately 6 months of age are more effective than are interventions with more global goals that begin during the early months. Recognizing the significance of this early relationship, however, has not resulted in a large number of attachment-based interventions. A variety of early parent education and home-visitation programs exist, but very few have as their primary goal facilitating the development of a secure attachment relationship (Egeland, 2009). There are some promising examples of interventions that encourage and facilitate a positive mother–infant relationship in the postpartum period (Buultjens, Robinson, & Liamputtong, 2008; Cooper et al., 2009; Dugravier et al., 2013; Murray, Cooper, Wilson, & Romaniuk, 2003; Toth, Rogosch, Manl, & Cicchetti, 2006; van Doesum, Riksen-Walraven, Hosman, & Hoefnagels, 2008). Results of the reviewed studies clearly show that antenatal depression has important adverse consequences to the pregnancy outcome besides being the main risk factor for postnatal depression. A considerable number of prenatal screening tools have been developed to detect its symptoms. Despite this, most of the preventive programs are realized in the postpartum period, and there are no publications available to outline interventions specific to the mother–infant relationship before childbirth. Identifying a woman’s risk for postpartum depression can begin many months before she gives birth and can continue through pregnancy and into the first year postpartum. Based on these results, we recommend incorporating attachment-based intervention/prevention programs into healthcare protocols before a woman gives birth. Preventive antenatal education programs can positively affect the mother–fetus relationship in the gestational period and enhance later attachment. There is a need for complex prevention programs focusing on the detection of the symptoms and on the preventive education in a period when women have more time and the capacity to prepare themselves for the maternal role.



361

REFERENCES Aceti, F., Baglioni, V., Ciolli, P., De Bei, F., Di Lorenzo, F., Ferracuti, S. et al. (2012). Maternal attachment patterns and personality in post partum depression [in Italian]. Rivista di psichiatria, 47(3), 214–20. doi:10.1708/1128.12443 Ainsworth, M.D. (1979). Infant—mother attachment. American Psychologist, 34(10), 932–937. Alder, J., Fink, N., Bitzer, J., H¨osli, I., & Holzgreve, W. (2007). Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. Journal of Maternal-Fetal & Neonatal Medicine, 20(3), 189–209. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text rev.). Washington, DC: Author. Andersson, L., Sundstr¨om-Poromaa, I., Wulff, M., Astr¨om, M., & Bixo, M. (2004a). Neonatal outcome following maternal antenatal depression and anxiety: A population-based study. American Journal of Epidemiology, 159(9), 872–881. Andersson, L., Sundstr¨om-Poromaa, I., Wulff, M., Astr¨om, M., & Bixo, M. (2004b). Implications of antenatal depression and anxiety for obstetric outcome. Obstetrics & Gynecology, 104, 467–76. Ayers, S., & Pickering, A.D. (2001). Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth, 28(2), 111–118. Bagner, D.M., Pettit, J.W., Lewinsohn, P.M., & Seeley, J.R. (2010). Effect of maternal depression on child behavior: A sensitive period? Journal of the American Academy of Child & Adolescent Psychiatry, 49(7), 699–707. doi:10.1016/j.jaac.2010.03.012 Bahri, M.R.Z., Hosseinian, S., Afrooz, G., & Hooman, H.A. (2011). The relationship between mothers’ biological and psychological characteristics and their babies’ levels of low birth weight. Australian Journal of Basic and Applied Sciences, 5(10), 848–854. Bakermans-Kranenburg, M.J., van IJzendoorn, M.H., & Juffer, F. (2003). Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129(2), 195– 215. Bansil, P., Kuklina, E.V., Meikle, S.F., Posner, S.F., Kourtis, A.P., Ellington, S.R. et al. (2010). Maternal and fetal outcomes among women with depression. Journal of Women’s Health, 19(2), 329–334. Barnes, D.L. (2006). Postpartum depression: Its impact on couples and marital satisfaction. Journal of Systemic Therapies, 25(3), 25–42. Beck, C.T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50(5), 275–285. Beebe, B., Badalamenti, A., Jaffe, J., Feldstein, S., Marquette, L., Helbraun, E. et al. (2008). Distressed mothers and their infants use a less efficient timing mechanism in creating expectancies of each other’s looking patterns. Journal of Psycholinguistic Research, 37(5), 293– 307. doi:10.1007/s10936-008-9078-y Bennett, H.A., Einarson, A., Taddio, A., Koren, G., & Einarson, T. R. (2004). Prevalence of depression during pregnancy: Systematic review. Obstetrics & Gynecology, 103, 698–709. Berle, J.Ø., Mykletun, A., Daltveit, A.K., Rasmussen, S., Holsten, F., & Dahl, A.A. (2005). Neonatal outcomes in offspring of women

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

362



E. Lefkovics, I. Baji, and J. Rig´o

with anxiety and depression during pregnancy. A linkage study from The Nord-Trøndelag Health Study (HUNT) and Medical Birth Registry of Norway. Archives of Women’s Mental Health, 8(3), 181–189. Bodecs, T., Horvath, B., Szilagyi, E., Gonda, X., Rihmer, Z., & Sandor, J. (2011). Effects of depression, anxiety, self-esteem, and health behaviour on neonatal outcomes in a population-based Hungarian sample. European Journal of Obstetrics, Gynecology, & Reproductive Biology, 154(1), 45–50. Bowlby, J. (1982). Attachment and loss (Vol. 1): Attachment (2nd ed.). New York: Basic Books. Buultjens, M., Robinson, P., & Liamputtong, P. (2008). A holistic programme for mothers with postnatal depression: Pilot study. Journal of Advanced Nursing, 63(2), 181–188. doi:10.1111/j.13652648.2008.04692.x Campbell, S.B., Brownell, C.A., Hungerford, A., Spieker, S.I., Mohan, R., & Blessing, J.S. (2004). The course of maternal depressive symptoms and maternal sensitivity as predictors of attachment security at 36 months. Development and Psychopathology, 16(2), 231–252. Cooper, P.J., Tomlinson, M., Swartz, L., Landman, M., Molteno, C., Stein, A. et al. (2009). Improving quality of mother–infant relationship and infant attachment in socioeconomically deprived community in South Africa: Randomised controlled trial. British Medical Journal, 338, b974. doi:10.1136/bmj.b974 Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. Cummings, E.M., & Kouros, C.D. (2009). Maternal depression and its relation to children’s development and adjustment. In R.E. Tremblay, R.G. Barr, RdeV Peters, & M. Boivin (Eds.), Encyclopedia on early childhood development (pp. 1–6) [online]. Montreal: Centre of Excellence for Early Childhood Development. Accessed October 28, 2009 Da Costa, D., Larouche, J., Drista, M., & Brender, W. (2000). Variation in stress levels over the course of pregnancy: Factors associated with elevated hassles, state anxiety and pregnancy-specific stress. Journal of Psychosomatic Research, 47, 609–621. Dayan, J., Creveuil, C., Herlicoviez, M., Herbel, C., Baranger, E., Savoye C., & Thouin A. (2002). Role of anxiety and depression in the onset of spontaneous preterm labor. American Journal of Epidemiology, 155, 293–301. Dayan, J., Creveuil, C., Marks, M.N., Conroy, S., Herlicoviez, M., Dreyfus, M. et al. (2006). Prenatal depression, prenatal anxiety, and spontaneous preterm birth: A prospective cohort study among women with early and regular care. Psychosomatic Medicine, 68, 938– 946. Deave, T., Heron, J., Evans, J., & Emond, A. (2008). The impact of maternal depression in pregnancy on early child development. BJOG: An International Journal of Obstetrics and Gynaecology, 115(8), 1043–1051. doi:10.1111/j.1471-0528.2008.01752.x Dennis, C.L., Heaman, M., & Vigod, S. (2012). Epidemiology of postpartum depressive symptoms among Canadian women: Regional and national results from a cross-sectional survey. Canadian Journal of Psychiatry, 57(9), 537–546.

Diego, M.A., Field, T., Hernandez-Reif, M., Schanberg, S., Kuhn, C., & Gonzalez-Quintero, V.H. (2009). Prenatal depression restricts fetal growth. Early Human Development, 85(1), 65–70. Diego, M.A., Jones, N.A., Field, T., Hernandez-Reif, M., Schanberg, S., Kuhn, C., & Gonzalez-Garcia, A. (2006). Maternal psychological distress, prenatal cortisol and fetal weight. Psychosomatic Medicine, 68(5), 747–753. Dugravier, R., Tubach, F., Saias, T., Guedeney, N., Pasquet, B. et al. (2013). Impact of a manualized multifocal perinatal homevisiting program using psychologists on postnatal depression: The CAPEDP Randomized Controlled Trial. PLOS ONE, 8(8), e72216. doi:10.1371/journal.pone.0072216 Edhborg, M., Nasreen, H.E., & Kabir, Z.N. (2011). Impact of postpartum depressive and anxiety symptoms on mothers’ emotional tie to their infants 2–3 months postpartum: A population-based study from rural Bangladesh. Archives of Women’s Mental Health, 14(4), 307–316. doi:10.1007/s00737-011-0221-7 Egeland, B. (2009). Attachment-based intervention and prevention programs for young children (Rev ed.). In M. van IJzendoorn (Topic ed.), R.E. Tremblay, M. Boivin, & RdeV Peters (Eds.), Encyclopedia on early childhood development (pp. 1–8) [online]. Montreal: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development. Retrieved November, 2009 from http://www.child-encyclopedia.com/ documents/EgelandANGxp_rev.pdf Feldman, R., Granat, A., Pariente, C., Kanety, H., Kuint, J., & Gilboa-Schechtman, E. (2009). Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity. Journal of the American Academy of Child & Adolescent Psychiatry, 48(9), 919–927. doi:10.1097/CHI.0b013e3181b21651 Feldman, R., Eidelman, A.I., & Rotenberg, N. (2004). Parenting stress, infant emotion regulation, maternal sensitivity, and the cognitive development of triplets: A model for parent and child influences in a unique ecology. Child Development, 75, 1774–1791. Field, T. (1992). Infants of depressed mothers. Development and Psychopathology, 4, 49–66. Field, T., Hernandez-Reif, M., Diego, M., Feijo L., Vera Y., Gil K. et al. (2007). Still-face and separation effects on depressed mother– infant interactions. Infant Mental Health Journal, 28(3), 314– 323. Field, T., Hernandez-Reif, M., Diego, M., Figueiredo, B., Schanberg, S. et al. (2006). Prenatal cortisol, prematurity and low birthweight. Infant Behavior & Development, 29(2), 268–275. Field, T., Diego, M., Hernandez-Reif, M., Deeds, O., Holder, V., Schanberg, S. et al. (2009). Depressed pregnant black women have a greater incidence of prematurity and low birthweight outcomes. Infant Behavior & Development, 32(1), 10–16. Field, T. (2010). Postpartum depression effects on early interactions, parenting, and safety practices: A review. Infant Behavior & Development, 33(1), 1–6. doi:10.1016/j.infbeh.2009.10.005 Forman, D.R., O’Hara, M.W., Stuart, S., Gorman, L.L., Larsen, K.E., & Coy, K.C. (2007). Effective treatment for postpartum depression is not sufficient to improve the developing mother–child relationship.

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Effects of Maternal Depression on Infants and Attachment

Development and Psychopathology, 19(2), 585–602. PubMed PMID: 17459185 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. Obstetreics & Gynecology, 106, 1071–1083. Gaynes, B.N., Gavin, N., Meltzer-Brody, S., Lohr, K.N., Swinson, T., Gartlehner, G. et al. (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes.Agency for Healthcare Research and Quality. (US) 1998–2005. AHRQ Evidence Report Summaries Evidence Report/Technology Assessment No. 119. Gilman, S.E., & Abraham, H.D. (2001). A longitudinal study of the order of onset of alcohol dependence and major depression. Drug and Alcohol Dependence, 63, 277–286. Gjerdingen, D.K., & Yawn, B.P. (2007). Postpartum depression screening: Importance, methods, barriers and recommendations for practice. Journal of the American Board of Family Medicine, 20(3), 280–288. Goedhart, G., Snijders, A.C., Hesselink, A.E., van Poppel, M.N., Bonsel, G.J., & Vrijkotte, T.G. (2010). Maternal depressive symptoms in relation to perinatal mortality and morbidity: Results from a large multiethnic cohort study. Psychosomatic Medicine, 72(8), 769–776. Goodman, S.H., & Brand, S.R. (2009). Infants of depressed mothers: Vulnerabilities, risk factors and protective factors for the later development of psychopatology. In C.H. Zeanah (Ed.), Handbook of infant mental health (3rd ed., pp. 153–170). New York: Guilford Press. Guedeney, A. (2007). Infant’s withdrawal and depression. Infant Mental Health Journal, 28(4), 399–408. Guedeney, A., Guedeney, N., Tereno, S., Dugravier, R., Greacen, T., Welniarz, B. et al. (2011). Infant rhythms versus parental time: Promoting parent–infant synchrony. Journal of Physiology-Paris, 105, 195–200. Guedeney, N., Fermanian, J., Guelfi, J.D., & Kumar, R.C. (2000). The Edinburgh Postnatal Depression Scale (EPDS) and the detection of major depressive disorders in early postpartum: Some concerns about false negatives. Journal of Affective Disorders, 61(1–2), 107–112. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56–62. Haslam, D., Pakenham, K., & Smith, A. (2006). Social support and postpartum depressive symptomatology: The mediating role of maternal self-efficacy. Infant Mental Health Journal, 27, 276–291. Hayes, L.J., Goodman, S.H., & Carlson, E. (2012). Maternal antenatal depression and infant disorganized attachment at 12 months. Attachment & Human Development, 15(2), 133–153. Hornstein, C., Trautmann-Villalba, P., Hohm, E., Rave, E., WortmannFleisher, S., & Schwarz, M. (2006). Maternal bond and mother–child interaction in severe postpartum psychiatric disorders: Is there a link? Archives of Women’s Mental Health, 9, 279–284. Kelly, R.H., Russo, J., & Katon, W. (2011). Somatic complaints among pregnant women cared for in obstetrics: Normal pregnancy or depressive and anxiety symptom amplification revisited? General Hospital Psychiatry, 23(3), 107–113. Kim, J.J., Gordon, T.E., La Porte, L.M., Adams, M., Kuendig, J.M., & Silver, R.K. (2008). The utility of maternal depression screening in



363

the third trimester. American Journal of Obstetrics & Gynecology, 199(5), 509.e1–e5. Kingston, D., Tough, S., & Whitfield, H. (2012). Prenatal and postpartum maternal psychological distress and infant development: A systematic review. Child Psychiatry & Human Development, 43(5), 683– 714. doi:10.1007/s10578-012-0291-4 Kroenke, K., Spitzer, R.L., Williams, J.B., & Lowe, B. (2009). An ultrabrief screening scale for anxiety and depression: The PHQ-4. Psychosomatics, 50(6), 613–621. Kumar, R.C. (1997). “Anybody’s child:” Severe disorders to mother-toinfant bonding. British Journal of Psychiatry, 171, 175–181. Kurki, T., Hiilesmaa, V., Raitasalo, R., Mattila, H., & Ylikorkala, O. (2000). Depression and anxiety in early pregnancy and risk for preeclampsia. Obstetrics & Gynecology, 95, 487–490. Larsson, C., Sydsj¨o, G., & Josefsson, A. (2004). Health, sociodemographic data and pregnancy outcome in women with antepartum depressive symptoms. Obstetrics & Gynecology, 104(3), 459–466. Leahy-Warren, P., McCarthy, G., & Corcoran, P. (2012). First-time mothers: Social support, maternal parental self-efficacy and postnatal depression. Journal of Clinical Nursing, 21(3–4), 388–397. Lefkowitz, D.S., Baxt, C., & Evans, J.R. (2010). Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU). Journal of Clinical Psychology in Medical Settings, 17(3), 230–237. Leigh, B., & Milgrom, J. (2008). Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry, 8, 24. Li, D., Liu, L., & Odouli, R. (2009). Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: A prospective cohort study. Human Reproduction, 24, 146–153. Lyons-Ruth, K., Lyubchik, A., Wolfe, R., & Bronfman, E. (2002). In S.H. Goodman, & I.H. Gotlib (Eds.), Children of depressed parents: Mechanisms of risk and implications for treatment (pp. 89–120). Washington, DC: American Psychological Association. Mancuso, R.A., Schetter, C.D., Rini, C.M., Roesch, S.C., & Hobel, C.J. (2004). Maternal prenatal anxiety and corticotropin-releasing hormone associated with timing of delivery. Psychosomatic Medicine, 66, 762–769. Marcus, S.M. (2009). Depression during pregnancy: Rates, risks and consequences-Motherisk Update 2008. Canadian Journal of Clinical Pharmacology, 16(1), e15–e22. Martini, J., Knappe, S., Beesdo-Baum, K., Lieb, R., & Wittchen, H.U. (2010). Anxiety disorders before birth and self-perceived distress during pregnancy: Associations with maternal depression and obstetric, neonatal and early childhood outcomes. Early Human Development, 86(5), 305–310. Matthey, S., Guedeney, A., Starakis, N., & Barnett, B. (2005). Assessing the social behavior of infants: Use of the ADBB Scale and relationship to mother’s mood. Infant Mental Health Journal, 26, 442– 458. McElwain, N.L., & Booth-Laforce, C. (2006). Maternal sensitivity to infant distress and nondistress as predictors of infant– mother attachment security. Journal of Family Psychology, 20(2), 247–255.

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

364



E. Lefkovics, I. Baji, and J. Rig´o

McFarland, J., Salisbury, A.L., Battle, C.L., Hawes, K., Halloran, K., & Lester, B.M. (2011). Major depressive disorder during pregnancy and emotional attachment to the fetus. Archives of Women’s Mental Health, 14(5), 425–434. McGrath, J.M., Records, K., & Rice, M. (2007). Maternal depression and infant temperament characteristics. Infant Behavior & Development, 31(1), 71–80. McMahon, C., Barnett, B., Kowalenko, N., & Tennant, C. (2005). Psychological factors associated with persistent postnatal depression: Past and current relationships, defence styles and the mediating role of insecure attachment style. Journal of Affective Disorders, 84(1), 15–24.

Noorlander, Y., Bergink, V., & van den Berg, M.P. (2008). Perceived and observed mother–child interaction at time of hospitalization and release in postpartum depression and psychosis. Archives of Women’s Mental Health, 11(1), 49–56. doi:10.1007/s00737-008-0217-0 Orr, S.T., James, S.A., & Blackmore, P.C. (2002). Maternal prenatal depressive symptoms and spontaneous preterm births among AfricanAmerican women in Baltimore, Maryland. American Journal of Epidemiology, 156, 797–802. Parsons, C.E., Young, K.S., Rochat, T.J., Kringelbach, M.L., & Stein, A. (2012). Postnatal depression and its effects on child development: A review of evidence from low- and middle-income countries. British Medical Bulletin, 101, 57–79. doi:10.1093/bmb/ldr047

McMahon, C.A., Barnett, B., Kowalenko, N.M., & Tennant, C.C. (2006). Maternal attachment state of mind moderates the impact of postnatal depression on infant attachment. Journal of Child Psychology and Psychiatry, 47(7), 660–669. Milgrom, J., Westley, D., & Gemmill, A.W. (2004). The mediating role of maternal responsiveness in some longer-term effects of postnatal depression on infant development. Infant Behavior & Development, 27, 443–454.

Qiao, Y., Wang, J., Li, J., & Wang, J. (2012). Effects of depressive and anxiety symptoms during pregnancy on pregnant, obstetric and neonatal outcomes: A follow-up study. Journal of Obstetrics & Gynaecology, 32(3), 237–240. Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.

Moehler, E., Brunner, R., Wiebel, A., Reck, C., & Resch, F. (2006). Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother–child bonding. Archives of Women’s Mental Health, 9(5), 273–278. Mulder, E.J.H., Robles de Medina, P.G., Huizink, A.C., Van den Bergh, B.R.H., Buitelaar, J.K., & Visser, G.H.A. (2002). Prenatal maternal stress: Effects on pregnancy and the (unborn) child. Early Human Development, 70, 3–14. Murray, L., & Carothers, A. (1990). The validation of the Edinburgh Postnatal Depression Scale on a community sample. British Journal of Psychiatry, 157, 288–290. Murray, L. (1992). The impact of postnatal depression on infant development. Journal of Child Psychology and Psychiatry, 33(3), 543–561. Murray, L., Cooper, P.J., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother–child relationship and child outcome. British Journal of Psychiatry, 182, 420– 427. Murray, L., Halligan, S., & Cooper, P. (2010). Effects of postnatal depression on mother-infant interactions, and child development. In Bremner, J. G., & Wachs, T. D. (Eds.), The Wiley-Blackwell Handbook of Infant Development. Volume II: Applied and Policy Issues. (2nd ed., pp. 192–220). New York: John Wiley, ISBN 9781405178747 Nagata, M., Nagai, Y., Sobajima, H., Ando, T., & Honjo, S. (2003). Depression in the mother and maternal attachment—Results from a follow-up study at 1 year postpartum. Psychopathology, 36(3), 142– 151. Neggers, Y., Goldenberg, R., Cliver, S., & Hauth, J. (2006). The relationship between psychosocial profile, health practices, and pregnancy outcomes. Acta Obstetricia et Gynecologica Scandinavica, 85, 277– 285. Nicholson, W.K., Setse, R., Hill-Briggs, F., Cooper, L.A., Strobino, D., & Powe, N.P. (2006). Depressive symptoms and health-related quality of life in early pregnancy. Obstettrics & Gynecology, 107, 798–806.

Rahman, A., Bunn, J., Lovel, H., & Creed, F. (2007). Association between antenatal depression and low birthweight in a developing country. Acta Psychiatrica Scandinavica, 115, 481–486. Righetti-Veltema, M., Bousquet, A., & Manzano, J. (2003). Impact of postpartum depressive symptoms on mother and her 18-month-old infant. European Child & Adolescent Psychiatry, 12(2), 75–83. Righetti-Veltema, M., Conne-Perr´eard, E., Bousquet, A., & Manzano, J. (2002). Postpartum depression and mother–infant relationship at 3 months old. Journal of Affective Disorders, 70, 291–306. Robbins Broth, M., Goodman, S.H., Hall, C., & Raynor, L.C. (2004). Depressed and well mothers’ emotion interpretation accuracy and the quality of mother–infant interaction. Infancy, 6(1), 37–55. Robertson, E., Grace, S., Wallington, T.M., & Stewart, D.E. (2004). Antenatal risk factors for postpartum depression: A synthesis of recent literature. General Hospital Psychiatry, 26(4), 289–295. Rogosch, F.A., Cicchetti, D., & Toth, S.L. (2004). Expressed emotion in multiple subsystems of the families of toddlers with depressed mothers. Development and Psychopathology, 16(3), 689–709. Rondo, P.H., Ferreira, R.F., Nogueira, F., Ribeiro, M.C., Lobert, H., & Artes, R. (2003). Maternal psychological stress and distress as predictors of low birth weight, prematurity and intrauterine growth retardation. European Journal of Clinical Nutrition, 57, 266–272. Scharfe, E. (2007). Cause or consequense?: Exploring causal links between attachment and depression. Journal of Social and Clinical Psychology, 26, 1048–1064. Soderquist, J., Wijma, B., Thorbert, G., & Wijma, K. (2009). Risk factors in pregnancy for post-traumatic stress and depression after childbirth. BJOG: An International Journal of Obstetrics and Gynaecology, 16(5), 672–680. Sohr-Preston, S.L., & Scaramella, L.V. (2006). Implications of maternal depressive symptoms for early cognitive language development. Clinical Child and Family Psychology Review, 9, 65–83. Spielberger, C., Gorsuch, R., & Lushene, R. (1970). The state/trait anxiety inventory. Paolo Alto, CA: Consulting Psychology Press.

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Effects of Maternal Depression on Infants and Attachment

Spitzer, R.L., Williams, J.B., Gibbon, M., & First, M.B. (1992). The structured clinical interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49, 624–629. Stapleton, L.R., Schetter, C.D., Westling, E., Rini, C., Glynn, L.M., Hobel, C.J. et al. (2012). Perceived partner support in pregnancy predicts lower maternal and infant distress. Journal of Family Psychology, 26(3), 453–463. doi:10.1037/a0028332 Stein, A., Craske, M.G., Lehtonen, A., Harvey, A., Savage-McGlynn, E., Davies, B. et al. (2012). Maternal cognitions and mother–infant interaction in postnatal depression and generalized anxiety disorder. Journal of Abnormal Psychology. Advance online publication. doi:10.1037/a0026847 Straub, H., Adams, M., & Kim, J.J. (2012). Antenatal depressive symptoms increase the likelihood of preterm birth. American Journal of Obstetrics & Gynecology, 207, 329.e1–e4. Tharner, A., Luijk, M.P., van IJzendoorn, M.H., Bakermans-Kranenburg, M.J., Jaddoe, V.W., Hofman, A. et al. (2012). Maternal lifetime history of depression and depressive symptoms in the prenatal and early postnatal period do not predict infant–mother attachment quality in a large, population-based Dutch cohort study. Attachment & Human Development, 14(1), 63–81. doi:10.1080/14616734.2012.636659 Tikotzky, L., Chambers, A.S., Gaylor, E., & Manber, R. (2010). Maternal sleep and depressive symptoms: Links with infant negative affectivity. Infant Behavior & Development, 33(4), 605–612. Tomlinson, M., Cooper, P., & Murray, L. (2005). The mother–infant relationship and infant attachment in a South African peri-urban settlement. Child Development, 76(5), 1044–1054. Toth, S.L., Rogosch, F.A., Manly, J.T., & Cicchetti, D.J. (2006). The efficacy of toddler–parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder:



365

A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74(6), 1006–1016. Toth, S.L., Rogosch, F.A., Sturge-Apple, M., & Cicchetti, D. (2009). Maternal depression, children’s attachment security, and representational development: An organizational perspective. Child Development, 80(1), 192–208. Tronick, E., & Reck, C. (2009). Infants of depressed mothers. Harvard Review of Psychiatry, 17, 147–156. Van Dijk, A.E., Van Eijsden, M., Stronks, K., Gemke, R.J., & Vrijkotte, T.G. (2010). Maternal depressive symptoms, serum folate status, and pregnancy outcome: Results of the Amsterdam Born Children and their Development study. American Journal of Obstetrics & Gynecology, 203(6), 563.e1–e7. Van Doesum, K.T., Riksen-Walraven, J.M., Hosman, C.M., & Hoefnagels, C. (2008). A randomized controlled trial of a home-visiting intervention aimed at preventing relationship problems in depressed mothers and their infants. Child Development, 79(3), 547–561. doi:10.1111/j.1467-8624.2008.01142.x Wallis, A.B., & Saftlas, A.F. (2009). Is there a relationship between prenatal depression and preeclampsia? American Journal of Hypertension, 22, 345–346. Wan, M.W., & Green, J. (2009). The impact of maternal psychopathology on child–mother attachment. Archives of Women’s Mental Health, 12, 123–134. Waxler, E., Thelen, K., & Muzik, M. (2011). Maternal perinatal depression—Impact on infant and child development. European Psychiatric Review, 4(1), 41–47. Winnicott, D.W. (1987). Babies and their mothers. New York: Addison Wesley. Zigmond, A.S., & Snaith, R.P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370.

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Impact of maternal depression on pregnancies and on early attachment.

The relatively high prevalence and duration of depression in the prenatal and postpartum periods reinforce the need for better understanding of matern...
305KB Sizes 4 Downloads 14 Views