the course of postpartum depression: a review of ......the children.7,8 indeed, mothers suffering...

REVIEW

The Course of Postpartum Depression: A Review ofLongitudinal Studies

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Nicole Vliegen, PhD,* Sara Casalin, PhD,* and Patrick Luyten, PhD

Learning Objectives: After participating in this educational activity, the physician should be better able to1. Identify the risk factors associated with persistence of postpartum depression.2. Evaluate the limitations of the literature.3. Determine the implications of the findings on women with postpartum depression and their children.This article aims to critically review studies published between 1985 and 2012 concerning the course of postpartumdepression (PPD), as well as factors implicated in PPD with a chronic course. We provide a systematic, qualitative re-view of studies on the course of PPD, following PRISMA guidelines. The results show that although the majority ofwomen recover from PPD, it becomes chronic in a relatively large subgroup of women. Several studies have identifiedrisk factors predicting a chronic course of PPD. This review also emphasizes and discusses important conceptual andmethodological limitations in existing research, which preclude drawing strong conclusions. Finally, the implicationsof these findings and suggestions for future research and clinical intervention are outlined.

Keywords: chronic depression, course and severity, longitudinal studies, postpartum depression

Alarge body of research has documented the associa-tion between maternal depression and adverseoutcomes in offspring (for a review, see Downey

& Coyne1 and Weissman et al.2). Several studies suggestthat these adverse effects are especially pronounced inmothers who suffer from chronic depression.3–5 Further-more, maternal chronic depression may be especially harm-ful in infancy since children are exposed to maternaldisengagement and negative affect during their earliestmonths of life, a sensitive developmental period; this ex-perience carries the risk of impairing their cognitive andverbal abilities and school readiness, and of leading to psy-chological problems.6 It has also been shown that the sever-ity and chronicity of maternal depression, rather than itsdiagnosis per se, are related to negative outcomes inthe children.7,8 Indeed, mothers suffering from chronic

he Faculty of Psychology and Educational Services, University of; Research Department of Clinical, Educational and Health Psychol-niversity College London (Dr. Luyten).

al manuscript received 3 February 2013; revised manuscript receivedy 2013, accepted for publication subject to revision 24 July 2013;manuscripts received 15 September 2013 and 13 October 2013.

pondence: Sara Casalin, PhD, Department of Psychology, Universityen, Tiensestraat 102 bus 3720, 3000 Leuven, [email protected]

Harvard Review of Psychiatry offers CME for readers who completens about featured articles. Questions can be accessed from thed Review of Psychiatry website (www.harvardreviewofpsychiatry.org)ing the CME tab. Please read the featured article and then log into thefor this educational offering. If you are already online, click here to goto the CME page for further information.

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Copyright @ 2014 President and Fellows of Harvard Colle

depression, compared to those with intermittent, episodic,or transient depression, have been shown to be less posi-tive, sensitive, and engaged with their infants.4,6,9 It is clearthat more knowledge about the course of postpartum de-pression is urgently needed. Mothers’ depression after thebirth of their children may have significant, prolonged neg-ative consequences not just for the mothers themselves butalso for the children.

Although pregnancy is typically associated with ex-pectations of new motherhood as a happy time, for asubstantial number of mothers the postpartum period isprimarily associated with feelings of sadness, fear, andloneliness. Between 50% and 80% of new mothers experi-ence an episode of the “baby blues,” characterized by mildbut unmistakable sadness, exhaustion, unstable mood, andfear.10 For mothers with full-blown postpartum depres-sion (PPD), however, this period is even more difficult. IntheDiagnostic and Statistical Manual of Mental Disorders(DSM-IV),11 PPD is defined as a current, or the most re-cent, episode of major depressive disorder (MDD) or of bi-polar I or bipolar II disorder, if the episode has an onsetwithin four weeks postpartum. Based on a meta-analysisof 59 studies using both self-report questionnaires anddiagnostic interviews, O’Hara and Swain12 estimated theprevalence of PPD to be 13%. They also found that theprevalence of PPD was slightly, although significantly,higher when assessed with self-report questionnaires (14%)compared to diagnostic interviews (12%). A more recentreview by Gavin and colleagues13 excluded studies using

* The first two authors contributed equally to this article.

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ge. Unauthorized reproduction of this article is prohibited.

N. Vliegen et al.

only self-report measures of PPD and found the prevalenceof major depression during the first three months postpar-tum to be 7.1%. During this early postpartum period,mothers are at heightened risk for depression,14,15 andthe number of depressive episodes can be twice as high asduring other periods in a woman’s life.16 During the firstthree months postpartum, parents are also at increased riskof hospital admission for mental disorders compared tononparents of the same age,17 with the highest risk of admis-sion between 10 and 19 days postpartum.17 This pattern,however, changes with increasing age: the risk of admissionwas found to be higher among nonparents, compared toage-matched parents, starting at about 30 years of age.

Because PPD has significant consequences for the baby,the depressed mother, and the early relationship betweenmother and child, knowledge about prolonged changes inthe mental health of mothers with PPD may not only im-prove our understanding of the course of PPD but also in-form prevention and intervention strategies.18

Hence, this article systematically reviews longitudinalstudies that have examined the course of PPD, followingthe guidelines of the PRISMA statement.19 It addresses thefollowing questions: (1) How does PPD evolve beyond thepostpartum period? Has empirical research identified dif-ferent trajectories in processes of recovery? (2) Does the lit-erature identify factors influencing the course of PPD?Which factors have been studied, and what are the con-clusions that can be drawn from this body of literature? Thediscussion of the main results is followed by a broad dis-cussion of the limitations of existing research that affect theinterpretability and generalizability of research findings.Issues discussed are the conceptualization of PPD and its se-verity and chronicity; postpartum onset of depression versusprevious vulnerability; the instruments used to assess PPDand its course; the samples investigated; and the role oftreatment.

METHODSFor this review, empirical studies published in peer-reviewedjournals in English between 1 January 1985 and 1 August2012 were retrieved using several search engines (PubMed,PsycINFO, Lime, Google Scholar, and LibriSource) and thefollowing combinations of subject headings: longitudinalresearch, follow-up, postpartum, postnatal, depression, de-pressive symptoms, depressive symptomatology, course,and chronic depression. The data search revealed 64 records.Studies were then screened according to five inclusion/exclusion criteria: (1) The study investigated PPD withinthe first three months after giving birth, since diagnosticcriteria specify that the onset of PPD should be within fourweeks postpartum and since PPD most frequently occurs inthe first three months postpartum.20 Studies that assessedPPD later than three months after childbirth were includedonly if they focused on PPD during the first three monthsafter birth—for example, by assessing symptoms at some

2 www.harvardreviewofpsychiatry.org

Copyright @ 2014 President and Fellows of Harvard College. U

point during the first three months postpartum using a psy-chiatric interview (see below). (2) The study had a pro-spective, longitudinal design that included at least a secondmeasure of depressive symptomatology beyond the post-partum period (e.g., at 3 months). (3) The study presentedquantitative data for the PPD group (e.g., mean scores,correlations, prevalences) on clearly defined time pointsfrom childbirth. (4) Studies that did not differentiate betweenmothers with and without PPD were not considered fur-ther for review. (5) Studies on postpartum psychosis orbipolar affective disorders were excluded.

After two of the authors (NV and SC) screened for theseinclusion and exclusion criteria, 23 longitudinal studieswere identified for this review. A detailed list of studiesexcluded from the review can be obtained from the firstauthor. Of the 23 included studies, 18 were conducted incommunity samples, and 5 used clinical samples (for anoverview, see Tables 1 & 2). Sociodemographic or other riskfactors for PPDwere investigated in 15 of the reviewed studies.

RESULTS I: LONGITUDINAL COURSE OF PPDResearch on the course of PPD has examined (1) the sever-ity of depression (mean depression rates on a depressionquestionnaire) over time, (2) the prevalence of depressionafter the postpartum period, or (3) different subgroups ofwomen with PPD. In the following sections, we presentthe results of the 23 studies that we reviewed.

Severity of Depressive SymptomatologySeven studies—four conducted in community samples23,26,28,29

and three in clinical samples37,39,42 (see Table 3)—investigatedmean depression levels in the postnatal period. All the studiesfound decreasing depression scores over time. Follow-up inthese studies ranged from 1 to 3.5 years. Two studies foundthat there was a statistically significant decrease in depres-sion between initial assessment and follow-up,29,42 whereasfour studies described a decrease but did not calculate sta-tistical significance.26,28,38,39 Holden and colleagues23 founda slight but statistically nonsignificant decrease in the levelof depression in a sample of mothers who did not receivetreatment for PPD, compared to a significant decrease in asample who were treated.

In four studies, the mean level of depression decreasedto below the cutoff value for depression defined in eachstudy;23,26,28,38 and in the other three studies, the levelof depression at follow-up remained above the cut-off.23,29,42,43 In the study by Holden and colleagues,23 de-pression levels decreased below the cutoff for the treatedmothers but not for the control sample (see Table 3). In thestudy by Milgrom and Beatrice,39 a cutoff score for theHamilton Depression Rating Scale (HDRS) was not reported.

In summary, these studies suggest that the severity ofPPD decreases over time, consistent with the 1991 resultsof Cooper and colleagues,44 who stated that a majority ofdepressive episodes after childbirth resolve within three to

Volume 22 • Number 1 • January/February 2014

nauthorized reproduction of this article is prohibited.

Table1

Reviewed

Long

itudina

lStudies

onPo

stpa

rtum

Dep

ressionin

Com

mun

itySamples

Partic

ipan

tsAssessm

enttim

epostpartum

Mea

suresofmaternal

symptomatology

Types

of

results

a

Wrate

etal.(1985),2

1

follo

w-upofCoxet

al.(1982)22

30PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=105):

11PPD

16postnatal

symptoms

T1:with

in1wee

k

T2:3–

5months

T3:3ye

ars

Atalltim

epoints:SP

I(2),(3)

Holden

etal.(1989)23

50PP

D(recruite

dfrom

aco

mmun

itysample,

n=73

4):

26PPD

in8wee

ksofco

unselin

gprovided

byhea

lthvisitors

24PPD

controls(noco

unselin

g)

T1:6&

12wee

ks

T2:25wee

ks

Atalltim

epoints:EP

DS(cutoff≥12),SP

I(1),(2)

Cam

pbell&

Coh

n(199

7),24ba

sed

onCam

pbelle

tal.(199

5)4

130subjects(rec

ruite

dfrom

aco

mmunity

sample,n=2760):

67PPD

63nondep

ressed

mothers

T1:2months

T2:4months

T3:6months

T4:9months

T5:12months

T6:18months

T7:24months

Atalltim

epoints:CES

-D,RDC,SA

DS

(2),(3),

(4)

Viin

amäkiet

al.(1997)25

39with

“minorpsych

iatric

disorder”(rec

ruite

dfrom

aco

mmunity

sample,

n=139;maternity

centerforroutin

ehea

lthch

ecku

p)

T1:4–

8wee

ks

T2:2ye

ars

Atalltim

epoints:GHQ,ZSD

S(2),(3),

(4)

NICHD

EarlyChild

Care

Resea

rchNetwork

(1999)6

552PPD

(rec

ruite

dfrom

aco

mmunity

sample,

n=1215;U.S.hospita

ls)

T1:1mth

T2:6months

T3:15months

T4:24months

T5:36months

Atalltim

epoints:CES-D

(cutoff>16)

(2),(3)

Edhborg

etal.(2000)26

22PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=326)

T1:2months

T2:1ye

ar

Atalltim

epoints:EP

DS(cutoff≥12)

AtT1:ICQ

(both

paren

ts)

AtT2:EM

Q/EFQ

(both

paren

ts)

(1),(2),

(4)

Zelko

witz

&Mile

t(2001)27

20PPD-affe

cted

mothers(from

sample

ofwomen

with

postpartum

psych

iatric

disorder,n=48)

50co

ntrols

T1:2months

T2:6months

Atalltim

epoints:EP

DS(cutoff≥10),LIFE

,PSI,

SCID

,SC

L-90-R

(2),(4)

Contin

ued

onnextpage

Course of Postpartum Depression

Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 3

Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.

Table1

Con

tinue

d

Partic

ipan

tsAssessm

enttim

epostpartum

Mea

suresofmaternal

symptomatology

Types

of

results

a

Bee

ghly

etal.(2002)28

48PPD

(CES

-D>16;recruite

dfrom

aco

mmunity

cohort,n=106)

57nondep

ressed

mothers

(CES

-D=2–

12)

T1:2months

T2:3months

T3:6months

T4:12months

Atalltim

epoints:CES

-D(1),(2),

(3),(4)

Cam

pbelle

tal.(2004),9

based

on

NICHD

(1999)6

385

PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=1077;U.S.hospita

ls)

T1:1month

T2:6months

T3:15months

T4:24months

T5:36months

Atalltim

epoints:CES

-D(cutoff≥16)

(2),(3),

(4)

Horowitz

&Goodman

(2004)29

62PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=563)

T1:2–

4wee

ks

T2:4–

8wee

ks

T3:10–

14wee

ks

T4:14–

18wee

ks

T5:2ye

ars

AtT1:EP

DS(cutoff≥10),PSI

Atother

timepoints:BDI-II(cutoff≥14)

(1),(2),

(4)

Seim

yret

al.(2004)30

54

PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=272)

T1:2months

T2:1ye

ar

Atalltim

epoints:EP

DS(cutoff≥9/10)

(2),(4)

Cam

pbelletal.(200

7),31follo

w-up

ofNICHD

(199

9)6

215PPD

(recruite

dfrom

aco

mmunity

sample,n=1261)

T1–

T5

T6:4.5

years

T7:7ye

ars

Atalltim

epoints:CES

-D(cutoff≥16)

(3)

Ashman

etal.(2008)3

159PPD

(rec

ruite

dfrom

hospita

ls,

clinics,new

spap

ers,etc.)

T1:14months

T2:24months

T3:3.5

years

T4:4.5

years

T5:6.5

years

Atalltim

epoints:C

ES-D

(cutoff>16),LIFE,SCID

Family

contextual

risk

factors:co

mposite

scores

ofDAS,

FES,

LES,

PSI,SS

Q

(3),(4)

Klie

ret

al.(2008)32

14PP

D(recruitedfro

macommun

itysample,

n=10

5;Vienn

a)T1:at

birth

T2:6months

T3:18months

AtT1:structuredpsych

iatric

interview,EP

I(risk

index

,crea

tedbysumming7risk

variab

les)

AtT2&

T3:EP

DS(cutoff≥10/11)

(4)

Blabe

yet

al.(20

09)33

104

PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=444;Alaska)

T1:3.6

months

T2:2ye

arslater

AtT

1:PR

AMS(tw

oDSM

-IVde

pressive

symptom

s&risk

factorsforch

ronicde

pression

)

AtT2:CUBS

(2),(4)

Contin

ued

onnextpage

N. Vliegen et al.

4 www.harvardreviewofpsychiatry.org Volume 22 • Number 1 • January/February 2014


Table1

Con

tinue

d

Partic

ipan

tsAssessm

enttim

epostpartum

Mea

suresofmaternal

symptomatology

Types

of

results

a

Cam

pbellet

al.(2009),3

4based

onNICHD

(1999)6

270PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=1357)

T1–

T7:at

1month

and

then

everyyear

T8:9ye

ars

T9:11

years

T10:12ye

ars

Atalltim

epoints:CES-D

(cutoff≥16)

(3)

Howellet

al.(2009)35

215PPD

(rec

ruite

dfrom

aco

mmunity

sample,

n=563;En

glish-orSp

anish-spea

king

patientsin

anurban

U.S.tertiary

care

acad

emic

med

ical

center)

T1:2wee

ks

T2:6months

AtT1:trigge

rs&

buffe

rsofdep

ression

Atalltim

epoints:PHQ-2

(2),(3),

(4)

Glavinet

al.(2010)36

186PPD

(rec

ruite

dfrom

aco

mmunity

sample,n=2247):

128in

supportiveco

unselin

g

58in

trea

tmen

t-as-usual

condition

T1:6wee

ks

T2:3months

T3:6months

T4:12months

Atalltim

epoints:EP

DS(cutoff≥10)

(2)

aFo

urtypes

ofresults

aregive

n:(1)m

eandep

ressionleve

ls,(2)p

reva

lence

ofd

epressionafterthepostpartum

period,(3)subgroupsofd

epressed

mothers,an

d(4)influ

encing

factorswith

regard

toch

ronicity.

BDI,Bec

kDep

ressionInventory;B

DI-II,

Bec

kDep

ressionInventory,S

econ

dEd

ition;C

ES-D

,Cen

terforEp

idem

iologica

lStudiesDep

ressionSc

ale;

CUBS,

Child

hoodUnde

rstandingBeh

aviors

Survey;DAS,

Dya

dicAdjustmen

tSc

ale;

EMQ/EFQ

,Ex

perience

ofMotherhood/Fatherho

odQuestio

nnaire;EP

DS,

Edinbu

rghPostnatal

Dep

ressionSc

ale;EP

I,Ex

perience

ofPregn

ancy

Inter-

view

;FE

S,Fa

mily

Environmen

tSca

le;G

HQ,G

eneral

Hea

lthQuestio

nnaire;ICQ,InfantC

harac

teristic

Que

stionna

ire;

LES,

Life

Experience

sSu

rvey;L

IFE,

Longitudinal

Interval

Follo

w-upEval-

uation;PHQ-2,PatientHea

lthQuestio

nnaire;PPD,motherswith

postpartum

dep

ression;PRAMS,

Pregn

ancy

RiskAssessm

entMonito

ringSy

stem

;PSI,Pa

rentin

gStress

Index

;RDC,Resea

rch

Diagn

osticCriteria;SA

DS-L,Sc

hed

uleforA

ffectiveDisordersan

dSc

hizop

hrenia–Life

time;SC

ID,Structured

Clin

icalInterviewforD

SM-III-R;SCL-90-R,Sym

ptom

Chec

klist9

0–R;SPI,Stan

dard-

ized

Psych

iatric

Interview;SSQ,So

cial

Suppo

rtQue

stionnaire;ZSD

S,ZungSelf-RatingDep

ressionScale.




Table2

Reviewed

Long

itudina

lStudies

onPo

stpa

rtum

Dep

ressionin

Clin

ical

Samples

Partic

ipan

tsAssessm

enttim

epostpartum

Mea

suresofmaternal

symptomatology

Types

of

results

a

Buist(199

8)37(T1)

Buist&Janson

(200

1)38(T2)

45PPD

inpatients(23mothersreported

ahistory

ofch

ildhoodsexu

alab

use)

T1:when

child

was,onav

erag

e,3.9

monthsold

(betwee

n2.2

and

6.9

monthsold)

T2:when

child

was,onav

erag

e,36.8

monthsold

(betwee

n31an

d39monthsold)

AtT

1:fullpsychiatricinterview,B

DI

(cutoff≥

23),DAS,HDRS(cutoff

≥15

),MMI,NPI,P

BI,PS

E,PS

I,SSQ,STA

I

AtT2:BDI,DAS,

HDRS,

MMI,

PSE

,PSI,SS

Q,STAI

(1),(2),

(4)

Milg

rom

&Bea

trice

(2003)39

41PPD

inpatients

47nondep

ressed

mothers

T1:3months

T2:24months

Atalltim

epo

ints:B

DI(cu

toff≥17

),EP

DS

(cutoff>

12),HDRS

(1),(2)

McM

ahonet

al.

(2005)40

62PPD

recruite

dfrom

100mothers

admitted

toaparen

t-crafthospita

lfor

awee

k

T1:4months

T2:12months

Atalltim

epo

ints:A

SQ,C

ES-D

(cutoff>

16),

CIDI,DAS,DSQ

,PBI

(2),(4)

Cornish

etal.(20

08),4

1

follo

w-upof

McM

ahon

etal.(20

05)40

77PPD

recruite

dfrom

111primiparous

mothersin

a5-day

residen

tialprogram

forparen

tingproblems

T1:4months

T2:12months

T3:15months

AtT1&

T2:CID

I

Atalltim

epoints:CES-D

(cufoff≥16)

(2),(3),

(4)

Vliegenetal.(20

10)42

Vlie

genet

al.(2013)43

41PPD

inpatients

T1:d

uringpo

stpa

rtum

hospita

lization

T2:onav

erag

e,3.5

yearsafterT1

AtT1&

T2:BDI-II,

DEQ

AtT2:lifehistory

calendar

(1),(2),

(3),(4)

aFo

urtypes

ofresults

aregive

n:(1)m

eandep

ressionleve

ls,(2)p

reva

lence

ofd

epressionafterthepostpartum

period,(3)subgroupsofd

epressed

mothers,an

d(4)influ

encing

factorswith

regard

toch

ronicity.

ASQ

,Atta

chmen

tStyleQue

stionnaire

;BDI,Bec

kDep

ressionInventory;BDI-II,

BeckDep

ressionInventory,Se

cond

Edition;CES

-D,Cen

terforEp

idem

iologicalStudiesDep

ressionScale;

CID

I,Composite

International

Diagn

ostic

Interview;D

AS,

Dyadic

Adjustmen

tScale;D

EQ,D

epressiveExpe

rien

cesQuestio

nnaire;D

SQ,Defen

seStyleQuestio

nnaire;E

PDS,

Edinbu

rghPostnatal

De-

pressionSc

ale;

HDRS,

Ham

iltonDep

ressionRatingSc

ale;

MMI,MonashMother-Infan

tInteractionSc

ale;

NPI,Neo

natal

Perce

ptionInve

ntory

II;PBI,Paren

talB

ond

ingInstrumen

t;PPD,p

ostpa

r-tum

dep

ression;PSE,Paren

tingSe

lf-Effic

acySc

ale;

PSI,Paren

tingStress

Index

;SS

Q,So

cial

Suppo

rtQuestio

nnaire;STAI,State-TraitAnxietyInve

ntory.

N. Vliegen et al.



Table3

MeanLevelsof

Postpa

rtum

Dep

ressiveSymptom

atolog

yat

Initial

Assessm

enta

ndFo

llow-upPo

intsin

Com

mun

itySamples

andClin

ical

Samples

Meanlevelsofdep

ressivesymptomology

Other

conclusions

Com

mun

itysamples

Holden

etal.

(1989)23,a

Trea

tedmothers:

EPSD

mea

n=16at

T1;EP

SDmea

n=10.5

atT2(noSD

give

n)(p

<.001)

SPIsymptomsmea

n=25.5

atT1;SP

Isymptomsmea

n=14at

T2(noSD

give

n)

(p<.001)

Sign

ifica

ntch

ange

fortrea

tedmothers;

EPSD

mea

ndep

ression

leve

ldec

reased

toleve

lbelow

thecu

toffscore

(=12)

Controlgroup:

EPSD

mea

n=15.5

atT1;EP

SDmea

n=12at

T2(N

S)

SPIsymptomsmea

n=24at

T1;SP

Isymptomsmea

n=23at

T2(N

S)

Small/n

onsign

ificantch

ange

fornontreateddep

ressed

mothers;

EPSD

mea

ndep

ressionleve

lremained

above

thecu

toff

score

(=12)

Edhborg

etal.

(2000)26

EPSD

mea

n=15.5

(SD

=3.4,range

=13–

24)at

T1;EP

SDmea

n=7.6

(SD

=4.6)at

T2

EPSD

mea

ndep

ressionleve

ldec

reased

from

above

tobelow

the

cutoffscore

(=12)

Bee

ghly

etal.

(2002)28

CES

-Dmea

n=20.4

(SD

=5.2)at

T1;CES

-Dmea

n=13.1

(SD

=8.2)at

T3;CES

-Dmea

n=11

.4(SD

=8.2)at

T4

CES

-Dmea

ndep

ressionleve

ldec

reased

from

above

tobelow

thecu

toffscore

(=16)

Horowitz

&Goodman

(2004)29,a

EPSD

mea

n=14.12(SD

=7.34)a

tT2;E

PSD

mea

n=10.75(SD

=6.84)a

tT3;E

PSD

mea

n=10.65(SD

=6.87)at

T4;EP

SDmea

n=11

.57(SD

=9.49)at

T5

Sign

ifica

ntdec

reasebetwee

n4–

8wee

ks&

10–

12wee

ks(pairw

iseco

mparisons)

EPSD

mea

ndep

ressionleve

ldec

reased

butrem

ained

above

the

cutoffscore

(=10)

Clin

ical

samples

Buist(1998)37

(T1)

Buist&

Janson

(2001)38(T2)

Dep

ressed

motherswith

history

ofsexu

alab

use:

HDRSmea

n=18.7

(SD

=4)at

T1;HDRSmea

n=9.4

(SD

=6.7)at

T2

BDImea

n=36(SD

=9.3)at

T1;BDImea

n=13.2

(SD

=9.6)at

T2

SASmea

n=63.3

(SD

=11

.4)at

T1;SA

Smea

n=47.9

(SD

=16.1)at

T2

Dec

reased

tounder

thecu

toffscore

(15forHDRS;

23forBDI);

smallerdec

reasein

BDIdep

ressionleve

lin

PPD

mothers

Dep

ressed

motherswith

outhistory

ofsexu

alab

use

(n=22):

HDRSmea

n=18.7

(SD

=3.5)at

T1;HDRSmea

n=3.8

(SD

=3.8)at

T2

BDImea

n=30.1

(SD

=9.3)at

T1;BDImea

n=7.8

(SD

=6)at

T2

SASmea

n=55.7

(SD

=15.3)at

T1;SA

Smea

n=37.0

(SD

=13.1)at

T2

BDImea

ndep

ressionleve

ldec

reased

inPPD

mothersfrom

above

tobelow

thecu

toffscore

(15forHDRS;

23forBDI)

Milg

rom

&Bea

trice

(2003)39

Dep

ressed

sample:HDRSmea

n=13.3

(SD

=7.5)at

T1;HDRSmea

n=6.8

(SD

=6.8)at

T2

Nondep

ressed

sample:HDRSmea

n=3.2

(SD

=2.9)at

T1;HDRS

mea

n=2.6

(SD

=2.7)at

T2

HDRSmea

ndep

ressionleve

ldec

reased

Vlie

genet

al.

(2010)42,a

Vlie

genet

al.

(2013)43,a

BDImea

n=24.06(SD

=13.30)at

T1;BDImea

n=14.28(SD

=13.75)

atT2(t=4.63;p<.001)

BDI-IImea

ndep

ressionleve

ldec

reased

sign

ifica

ntly

from

highly

above

toslightly

above

thecu

toffscore

(=13)

aStudiesthat

calculatedthech

ange

inmea

ndep

ressionleve

love

rtim

e.

BDI,Bec

kDep

ressionInventory;B

DI-II,

BeckDep

ressionInventory,S

econd

Edition;C

ES-D

,Cen

terfor

Epidem

iologicalStudies

Dep

ressionScale;EP

SD,Edinb

urgh

Postna

talD

epressionScale;HDRS,

Ham

ilton

DepressionRatingScale;NS,no

nsignifican

t;PP

D,p

ostpartum

depression

;SAS,Sp

ielbergerAnxietyScale,statesubscale;SD,stand

arddeviation;

SPI,Stan

dardized

Psychiatric

Interview.




Table 4

Prevalence of Postpartum Depression Mothers That Meet Criteria for a Later Episode of Depression in CommunitySamples and Clinical Samples

3–4 months 6 months 9 months 12 months 18 months 24 months 3–3.5 years

Community samples

Wrate et al. (1985)21 62%

Holden et al. (1989)23 62%

Campbell & Cohn (1997)24 48% 30% 25% 24% 18% 13%

Viinamäki et al. (1997)25 31%

NICHD (1999)6 17%

Edhborg et al. (2000)26 6%

Zelkowitz & Milet (2001)27 62%

Beeghly et al. (2002)28 31% 35% 31%

Campbell et al. (2004)9 23%

Horowitz&Goodman (2004)29 27% 31%

Seimyr et al. (2004)30 39%

Blabey et al. (2009)33 46%

Howell et al. (2009)35 36%

Glavin et al. (2010)36 31.7% 27.8% 20.2%

Clinical samples

Buist (1998),37 Buist & Janson(2001)38

58%

Milgrom & Beatrice (2003)39 25%

McMahon et al. (2005)40 60%

Cornish et al. (2008)41 49%

Vliegen et al. (2010)42 39%

N. Vliegen et al.

six months. Depression levels do not always decrease to be-low the cutoff, however, and the decrease is not always sta-tistically significant. In addition, the standard deviationsare relatively high, indicating that change in depressionlevels within a sample is highly variable, suggesting that de-pressed mothers cannot be considered a homogeneousgroup (as discussed later in this review).

Prevalence of Depression After the Postpartum PeriodAll but three studies3,4,32 report prevalences at differentfollow-up time points, with various intervals (see Table 4).

Studies in community samples suggest that 27% to 48%(median = 31.3%) of mothers with PPD still met criteria formajor depression at 3 to 4 months postpartum (n = 4 stud-ies); 30% to 62% (median = 35.5%) at 6 months (n = 6studies); 25% to 31% (median = 28%) at 9 months (n =2 studies); 6% to 39% (median = 23.1%) at 12 months(n = 4 studies); 18% at 18 months (n = 1 study); 13% to46% (median = 31%) at 2 years (n = 4 studies); and 17%



to 62% (median = 38.5%) at 3 years (n = 2 studies). Over-all, these findings suggest that at any time point between4 months and 3 years postpartum, about 30% of mothersdiagnosed with PPD still meet criteria for depression.

In clinical samples, as might be expected, these figuresare even higher: 49% to 60% of mothers with PPD continueto satisfy criteria for major depression at 12 to 15 monthspostpartum (n = 2 studies); 25% do so at 24 months postpar-tum (n = 1 study); and 39% to 58% of mothers still havemajor depression at 3 to 3.5 years postpartum (n = 2 studies).

In sum, these results indicate that about 30% of PPD-affected mothers in community samples and about 50%in clinical samples remain depressed throughout and be-yond the first postnatal year.

Subgroups of Depressed MothersTwelve studies (ten conducted in community samples andtwo in clinical samples) focused on subgroups of depressedmothers (see Table 5).



Table5

Subg

roup

sof

PPD

Mothe

rsTh

atMet

CriteriaforaLaterEp

isod

eof

Dep

ressionin

Com

mun

itySamples

andClin

ical

Samples

Results

Com

mun

itysamples

Wrate

etal.(1985),2

1follo

w-upofCoxet

al.(1982)22

Seve

rity

ofdep

ressionat

baseline:

11(12%)seve

rely

dep

ressed

mothers(PPD)

16(17%)mild

lydep

ressed

mothers(PS)

Courseofdep

ression:

12(40%,a11

%b)c

hronically

dep

ressed

:n=2seve

rely

dep

ressed

(PPD);n=10mild

lydep

ressed

(PS)

15(16%

b)late

dep

ressed

:suffe

red≥

1dep

ressiveep

isodes

afterpostpartum

period

49(54%

b)nev

erdep

ressed

Cam

pbell&

Cohn(1997),2

4based

on

Cam

pbellet

al.(1995)4

Courseofdep

ression:

20(30%)ch

ronically

dep

ressed

(SADS≥

18)

27(41%)women

with

subclinical

symptoms(SADS≤

16)

19(29%)dep

ressionin

remission(SADS≤

14)

Viin

amäkiet

al.(1997)25

12(31%

,a9%

b)chron

icallyde

pressed:ZSD

Smean=41

.9(SD=5.2)atT1

;ZSD

Smean=44

.6(SD=9.5)atT2

27(69%,a19%

b)remitted

:ZSD

Smea

n=40.4

(SD

=5.2)at

T1;ZSD

Smea

n=34.4

(SD

=6.5)at

T2

100(72%

b)nev

erdep

ressed

:ZSD

Smea

n=32.9

(SD

=4.9)at

T1;ZSD

Smea

n=30.8

(SD

=6.2)at

T2

NICHD

EarlyChild

CareResea

rchNetwork

(1999)6

92(17%,a7.6%

b)ch

ronically

dep

ressed

:CES

-D>16,4or5tim

es

663(54.5%

b)nev

erdep

ressed

:CES

-D<16at

alltim

epoints

460(37.9%

b)sometim

esdep

ressed

:CES

-D>16,1to

3tim

es

Bee

ghly

etal.(2002)28

22(46%

a)ch

ronically

dep

ressed

:CES

-Dmea

n>12at

4assessmen

ttim

es

26(54%

a)remissiongroup

57(controlsample):CES

-Dmea

n≤

6.2

(SD

=5.0)at

4assessmen

ttim

es

Cam

pbellet

al.(2004),9

based

on

NICHD

(1999)6

Seve

rity

andco

urseofdep

ression(fu

rther

distin

ctionwith

inthe“sometim

esdep

ressed

”sample

ofthe

NICDH

study):

198(51%,a18.4%

b)remitted

mothers:CES

-D≥

16at

1,6,or15months

87(23%,a8.1%

b)ch

ronically

dep

ressed

:CES

-D≥

16,at

least3tim

epoints

100(26%,a9.3%

b)interm

itten

tlydep

ressed

:CES

-D≥16ataminim

um

of2

timepoints,sep

arated

bya

periodwith

CES

-D<16

Non-PPD

mothers:

594(55.1%

b)nev

erdep

ressed

:CES

-D<16at

alltim

epoints

98(9.1%

b)late

dep

ressed

:CES

-D≥

16at

24or36months

Contin

ued

onnextpage




Table5

Con

tinue

d

Results

Com

mun

itySa

mples

Cam

pbellet

al.(2007),3

1based

on

NICHD

(1999)6

Severity

&co

urseofdep

ression(fu

rther

distin

ctionwith

inthe“sometim

esdep

ressed

”sample

ofthe

NICHD

study):

31(14%,a2.5%

b)high–

chronic

mea

nCES

-Dfrom

32.8

(T1)to

27(T7)

73(34%,a6.2%

b)moderate–

increa

sing:

mea

nCES

-D=14.9

(T1);mea

nCES

-D=25.8

(T7)

71(33%,a5.6%

b)high–

dec

reasing:

mea

nCES

-Dfrom

25.5

(T1)to

13.2

(T7)

40(19%,a3.6%

b)interm

itten

t:marke

dva

riationsin

mea

nCES

-Dove

rtim

e

577(45.6%

b)low–stable:CES

-Dmea

nfrom

6.0

(T1)to

4.2

(T7)

469(36.4%

b)moderate–

stab

le(subclinical):CES

-Dmea

nfrom

12.2

(T1)to

10.5

(T7)

Ashman

etal.(2008)3

11(8%

a)ch

ronic

seve

redep

ression:av

erag

eCES

-Dscoresin

theclinical

range

&thehighestfreq

uen

cyofmajordep

ressiondiagn

osesat

alltim

epoints

40(30%

a)d

ecreasingdep

ressivesymptomsove

rtim

e:from

highto

moderate;from

majortosubthreshold

dep

ressiondiagn

oses

82(62%

a)stab

lemild

dep

ression,av

erag

eCES

-Dscoresbelow

clinical

range

:co

nsisten

tlylow

leve

lof

dep

ressiondiagn

osesthrough

outthestudy

Cam

pbellet

al.(2009),3

4based

on

NICHD

(1999)6

Severity

&co

urseofdep

ression(fu

rther

distin

ctionwith

inthe“sometim

esdep

ressed

”sample

ofthe

NICHD

study):

66(24%,a4.7%

b)ch

ronically

dep

ressed

:CES

-D≥

16at

alltim

epoints

59(22%

,a5.1%

b )early

anddecreasing:C

ES-D

≥16

mostofthe

time,with

adecreasetosubclinicallevelat24mon

ths

145(54%

,a10

.9%

b)m

oderatelyelevated

:CES-D

≥16

,with

ade

crease

tosubc

linicallevelsat6&15

mon

ths

416(30.8%

b)stab

lesubclinical:CES

-Dalway

s<16,but>nev

erdep

ressed

671(48.5%

b)nev

erdep

ressed

:CES

-D<16at

alltim

epoints

Howellet

al.(2009)35

PPD

sample:

78(36%,a14%

b)still

dep

ressed

atT2

137(64%,a24%

b)remissiongroup

Non-PPD

sample:

54(10%

b)late

onset(dep

ressed

atT2)

294(52%

b)nev

erdep

ressed

Clin

ical

samples

Cornishet

al.(2008)41(T3ofthesamesample

asdescribed

by

McM

ahonet

al.(2005))4

038(49%,a34%

b)ch

ronically

dep

ressed

:CES

-Dmea

n=18.0

(SD

=10.6)at

T1;CES

-Dmea

n=22.3

(SD

=10.1)at

T2;CES

-Dmea

n=22.4

(SD

=10)at

T3

39(51%,a35%

b)b

rief

dep

ression:C

ES-D

mea

n=11

.0(SD

=6.2)a

tT1;C

ES-D

mea

n=7.3

(SD

=4.7)a

tT2;CES

-Dmea

n=6.9

(SD

=4.4)at

T3

35(31%

b)n

on-dep

ressed

:CES

-Dmea

n=6.4

(SD=4.1)atT

1;C

ES-D

mea

n=5.4

(SD

=3.4)atT

2;C

ES-D

mea

n=6.3

(SD

=4.0)at

T3

Contin

ued

onnextpage

N. Vliegen et al.



Table5

Con

tinue

d

Results

Clin

ical

samples

Vlie

genet

al.(2010)42

Vlie

genet

al.(2013)43

16(39%

a)ch

ronically

dep

ressed

:BDImea

n=29.76(SD

=23.64)at

T1;BDImea

n=28.81

(SD

=11

.43)at

T2

25(61%

a)remitted

:BDImea

n=20.77(SD

=15.54)at

T1;BDImea

n=5.60(SD

=4.43)at

T2

aThepercentageiscalculatedonPPD

sample

only.

bThe

percentage

iscalculatedontotalsample

(norm

alco

ntrolsincluded

).BDI,BeckDep

ressionInve

ntory;C

ES-D

,Cen

terforEp

idem

iologica

lStudiesDep

ressionSc

ale;

PPD,p

ostpa

rtum

dep

ression;P

S,postna

talsym

ptoms;PSI,P

aren

tingStress

Index

;SADS,

Sched

ule

forAffe

ctiveDisordersan

dSchizop

hrenia;SD

,stan

darddeviatio

n;ZSD

S,ZungSelf-RatingDep

ressionScale.


Harvard Review of Psychiatry


Five of the studies specifically focused on the course ofthe depression. All five studies described two PPD groups.Howell and colleagues35 found a remission group reportingdepressive symptoms at baseline but not at 6 months, andan always-depressed group reporting depressive symp-toms both at baseline and at 6 months. A one-year28 anda two-year25 follow-up study also found improved andchronically depressed mothers. In a 15-month follow-upstudy of a clinical sample, Cornish and colleagues41 identi-fied mothers who were depressed for a short period—thatis, for no longer than one year postpartum—and thosewho were chronically depressed—that is, still depressed at15 months postpartum. In a sample of inpatient motherswith PPD, Vliegen and colleagues42,43 found remitted andchronic groups of mothers, with the latter being moder-ately to severely depressed at follow-up 3.5 years afterbaseline. Taking these results as a whole, all five studiesfound a group of mothers whose depression remitted, com-prising 51% to 64% of the sample of initially depressedmothers, and a second group who were chronically de-pressed, representing 36% to 49% of the sample.

Seven other studies distinguished subgroups on the ba-sis of both the course and severity of PPD. An early studyby Wrate and colleagues21 followed up a sample firstdescribed by Cox and colleagues.22 Initially, Cox andcolleagues22 delineated two groups of depressed mothersin this sample, one severely depressed and one with mildpostnatal symptoms. Of the total sample of 27 depressedmothers, 44% had subsequent depressive episodes. Wrateand colleagues21 found, quite surprisingly, that the groupwith mild postnatal symptoms had a higher risk (62%) ofdeveloping chronic depression three years later than theseverely depressed group (18%). Other studies includedseverity of depression but took it into account only atthe follow-up points. Campbell and colleagues,4,24 in atwo-year follow-up study, found three subgroups: remit-ted (29%), subclinical (41%), and chronic (30%). At twomonths postpartum, these three subgroups were equallysymptomatic and differed significantly from controls, butnot from each other, on total symptom ratings. By fourmonths, the subclinical and chronically depressed subgroupsshowed a significant and substantial decrease in symptomsrelative to their initial high levels. Only the remitted sub-group, however, had dropped to the level of the control groupon overall symptom ratings. Furthermore, only the chronicsubgroup continued to show statistically elevated levels ofdepression throughout the follow-up period, despite somevariability in symptom severity from one assessment tothe next.

In a subsequent study, Campbell and colleagues9 re-analyzed findings from the National Institute of ChildHealth and Human Development study.6 Based on as-sessments three years postpartum, they found five sub-groups, of which only two fell within the rubric of PPD:(1) early depressed (i.e., until 6 or 15 months; 18.4%



N. Vliegen et al.

of the total sample, or 69% of those with PPD), and(2) chronically depressed (i.e., for a period of 3 years;8.1% of the total, or 30% of those with PPD). The othersubgroups were (3) never depressed (55.1% of the total),(4) late depressed (i.e., depressed since two or three yearsafter childbirth; 9.1% of the total), and (5) intermittentlydepressed (i.e., experienced a minimum of two episodesof depression, but not necessarily in the postpartum period;9.3% of the total).

At seven-year follow-up of the same sample, Campbelland colleagues31 found six subgroups of depressedmothers, three of which can be considered to have PPD:(1) moderate–increasing (6.2% of the total communitysample, or 34% of those with PPD), (2) high–decreasing(i.e., partially remitted; 5.6% of the total, or 33% of thosewith PPD), and (3) high–chronic (i.e., remaining highly de-pressed; 2.5% of the total, or 14% of those with PPD).The three other trajectories that they found were (4) low–stable (i.e., very low symptomatology; 45.6% of the total),(5) moderate–stable, or subclinically depressed (36.4% ofthe total), and (6) intermittent (i.e., marked variations ofdepressed versus nondepressed status, but not necessarilyPPD; 3.6% of the total). At 12-year follow-up, Campbelland colleagues34 found evidence for five subgroups, threewith PPD: (1) early and decreasing (i.e., partial remissionsince 2 years postpartum; 5.1% of the total sample, or22% of those with PPD), (2) moderately elevated (i.e.,early partial remission; 10.9% of the total, or 54%of those with PPD), and (3) chronically depressed (4.7%of the total, or 24% of those with PPD). Others were(4) never depressed (48.5% of the total) and (5) stable sub-clinically depressed (30.8% of the total).

Ashman and colleagues3 identified three subgroups ofdepressed mothers in a follow-up study from childbirth toage 7: (1) decreasing depressive symptoms (30%), (2) sta-ble mild depression (i.e., consistent low level of depression;62%), and (3) chronic severe depression (8%).

To summarize, despite variability in the number ofsubgroups found by different studies, all have consistentlyreported a chronically depressed group—that is, PPDmothers who continue to show clinically elevated depres-sive symptomatology, with estimates of prevalence varyingbetween 23%9 and 49%41 (median = 38%). Most studies(with the exception of Ashman et al.3 and Wrate et al.21)also identified a remitted group—that is, mothers who ex-perience an acute major depression during the first threemonths postpartum but no longer show elevated symp-toms during follow-up (from 6 months to 3.5 years). Twostudies that followed up PPD mothers over a longer period(6.5 years3 and 7 to 12 years31,34), however, did not finda fully remitted group. More specifically, a decreasing de-pression group was identified, indicating a decrease fromhigh levels of depression at the baseline measurementto persisting subclinical depression at the final follow-uppoint.3,31,34 Hence, it seems that when the depressive



symptoms of mothers with PDD are examined for a longerfollow-up period, all mothers experience a relapse of depres-sive symptoms, although not always to a clinical level. Also,a subgroup of PPD mothers were found who showed stablesubclinical depressive symptoms throughout the study pe-riod.24,31,34 Although the authors did not specifically definethis last form as chronic, we highlight—consistent with theterminology in the PPD literature (see discussion)—that itis, in a strict sense, a chronic form of PPD. Furthermore, adistinction between high–chronic depression and so-calledmoderate–increasing depression has been made,31 with thelatter group comprising mothers who were moderately (sub-clinically) depressed during the postpartum period andshowed increasing levels of depressive symptoms that haverisen to a clinical level seven years postpartum.

Other studies have found subsamples of mothers whocould not be considered chronically depressed or remitted.These mothers are labeled as showing mild21 and stablemild3 depression.

RESULTS II: FACTORS PREDICTING THE COURSEOF PPDA considerable body of research has examined predictorsof the onset of PPD, eliciting eight factors that clearly pre-dict PPD: prenatal depression, a history of previous depres-sion, a lack of social support, life stress, child-care stress,“baby blues,” marital dissatisfaction, and prenatal anxiety(for a meta-analysis, see Beck).45 However, no one hasreviewed prospective studies that explore the risk factorsassociated with the persistence of PPD. Seventeen of the23 studies included in the present review investigatedsociodemographic or other risk factors, which we will dis-cuss in more detail below.

Sociodemographic Differences Between SubgroupsIn studies of the course of PPD, sociodemographic dif-ferences between depressed and nondepressed mothers orbetween different subgroups of depressed mothers areoften controlled for in order to minimize confoundinginfluences. In total, we identified 17 publications meet-ing the inclusion criteria of this review that examinedsociodemographic factors (see Table 6).

Of the 17 studies examining the factors that influencethe course of PPD, 4 studies either did not investigatesociodemographic differences between chronic and non-chronic PPD mothers8,21,23,25,36,37,39,42 or used matchedsamples.24

AGE Out of nine studies that investigated the impactof age, only three reported an association between thechild’s or mother’s age and chronic course of PPD.Ashman and colleagues3 found that mothers whose de-pressive symptoms declined over time had younger chil-dren than mothers with subclinical depression, although nodifference was found in the chronic depressive group.



Table6

Influ

encing

Factorswith

Regardto

Chron

icity

inPP

DMothe

rsTh

atMeetC

riteriaforaLaterEp

isod

eof

Dep

ressionin

Com

mun

itySamples

and

Clin

ical

Samples

Results

relatin

gto

dem

ograp

hic

variab

les

Results

relatin

gto

other

risk

factors

Com

mun

itysamples

Cam

pbell&

Cohn(1997)24

Nosociodem

ograp

hic

factors

wereinve

stigated

(bec

ause

ofmatch

edsamples)

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

spousalsupport

(F(3,84)=5.38;p<.002)

Nosign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

familial

or

personal

history

ofdep

ression

Viin

amäkiet

al.(1997)25

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

poorfin

ancial

situation(p

<.05)

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

(1)inad

equatesocial

support

(p<.0001);(2)subjectivemen

talproblemsbefore

&duringpregn

ancy

(p<.001),&

espec

ially

2ye

arslater(p

<.0001);(3)deterioratedrelatio

nship

with

partner

before

&duringpregn

ancy

(p<.05),&

espec

ially

2ye

arslater

(p<.0001);(4)stressfullifeev

entsafterdelivery(p

<.0001)&

(5)dep

ressive

symptomsin

postpartum

period(p

<.0001)

Highbaselinedep

ressionscoresco

mbined

with

adeterioratin

gpartner

relatio

nship

predictedch

ronicity

ofmen

talhea

lthproblems(lo

gistic

regressionan

alysis)

Edhborg

etal.(2000)26

Nodifferen

ceswerefound

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

stress

about

motherhood1ye

arpostpartum

(F(1,90)=12.30;p<.0006)

Zelko

witz

&Mile

t(2001)27

Sign

ificant

differenc

eswerefoun

dwith

regard

to(1)m

aterna

ledu

catio

n(t=−2

.1;p

<.05)

&(2)o

ccup

ationa

lstatus(χ2=10

.3;p

<.05)

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

history

ofmen

tal

hea

lthproblems(in

partic

ular,majordep

ression)

Bee

ghly

etal.(2002)28

Nosign

ifica

ntdifferen

ceswerefound(dueto

strict

inclusioncrite

ria)

Cam

pbell

etal.

(2004),9

based

onNICHD

(1999)6

Sign

ificant

differenc

eswerefoun

dwith

regard

to(1)levelof

educ

ation(F(2,1

212)

=38

.77;

p<.001

),(2)incom

e-to-needs

ratios(F(2,12

10)=

41.09;p<.001

)&(3)a

partn

erpresent(χ2

(2,121

5)=57

.30;p<.001

)

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

perce

ived

social

support(p

<.001)

Horowitz

&Goodman

(2004)29

Parity

&inco

mewereco

rrelated

with

dep

ressionat

T5;maternal

agewas

not

Dep

ressionhistory

(β=.423;p<.0001),lower

social

support(β

=.216;

p=.035)&

higher

paren

taldistress(β

=−.221;p=.036)were

sign

ifica

ntpredictors

ofdep

ressionat

T5

Seim

yret

al.(2004)30

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

finan

cial

worries(p

<.0001)

Nosign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

(1)losses

&strains,

(2)hea

lthproblems&

(3)partner

support

Ashman

etal.(2008)3

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

ageofthech

ildren

Contextual

risk

factors

wereassociated

with

maternal

dep

ression

(r=.46,p<.001)&

werestab

leove

rtim

e

Contin

ued

onnextpage




Table6

Con

tinue

d

Results

relatin

gto

dem

ograp

hic

variab

les

Results

relatin

gto

other

risk

factors

Com

mun

itysamples

Klie

ret

al.(2008)32

Nosign

ifica

ntdifferen

ceswerefound

Dep

ressivesymptomsat

T2predictedT3dep

ressivesymptomsev

enwhen

controllingfortheco

ntributio

nofmaternal

dep

ressionat

birth

(r=.44;p<.001)

Separated

psych

osocial

risk

factors

wereunrelatedto

thech

ronicity

ofPPD

Cumulativ

epsych

osocial

risk

(riskindex

)has

amoderatinginflu

ence

onthe

stab

ility

ofdep

ressivesymptomatology

:

Women

with

≥2outof7risk

factors

atbirth

weremore

likelyto

hav

estab

ledep

ressivesymptomatology

across

theinfant’s

first18monthsoflife

,from

T1to

T2

(r=0.36;p=.05)&

from

T2to

T3(r=0.55;p=.005)

Intercorrelationsam

ongthedep

ressionmea

suresat

all3tim

epointswerenot

sign

ifica

ntforwomen

with

fewer

than

2risk

factors

Blabey

etal.(2009)33

Nosign

ifica

ntdifferen

ceswerefound

Aco

ntrollingpartner

was

sign

ifica

ntly

associated

with

persisten

tPPD

(OR=6.9,

95%

CI=1.5–3

1.8;p=.014)

Howellet

al.(2009)35

Proportionally

fewer

chronically

dep

ressed

mothers

werewhite

(OR=2.90,95%

CI=1.33–

6.33)

Chronically

dep

ressed

mothersweremore

likelyto

hav

eahistory

ofdep

ression

(OR=4.24,95%

CI=1.93–9

.32)than

other

subgroups

Chronically

dep

ressed

&remitted

mothersreported

thesameleve

lsofphysical

symptomsat

T1(M

diff=−0

.31,NS),butch

ronically

dep

ressed

mothersshowed

asm

allerreductionin

leve

lsofphysical

symptoms(M

diff=−0

.78;p<.05)

Self-effic

acyincrea

sedfrom

T1to

T2forremitted

mothers(F(1,136)=60.20;

p<.01)&

remained

unch

ange

din

thech

ronic

sample

(F(1,77)=0.43,NS)

Clin

ical

samples

Buist(1998)37

Nosociodem

ograp

hic

factors

wereinve

stigated

PPD

motherswith

ahistory

ofch

ildhoodsexu

alab

use

improve

dless

compared

tonon-abusedPPD

mothers(p

<.05forboth

HDRS&

SAS)

McM

ahonet

al.(2005)40

Beingnon–Englishspea

kingwas

sign

ifica

ntly

associated

with

depression

atT2

(Waldχ2

=5.04

;df

=1;

p=.02;

OR=1.13

)

Thefollo

wingfactorsweresign

ificantlyassociated

with

depression

atT2

:(1)dep

ressionscoreatT1

(Waldχ2

=13

.59;df=1;p=.00;OR=1.35

),(2)low

materna

lcare

during

child

hood

(Waldχ2

=7.12

;df

=1;

p=.01;

OR=1.10

),(3)an

xietyov

errelatio

nships

(Waldχ2

=6.80

;df=

1;p=.01;

OR=1.18

),(4)immaturede

fensestyle

(Waldχ2

=7.38

;df=

1;p=.01;

OR=1.05

)&(5)low

maritalsatisfactionatT1

(Wald

χ2=5.04

;df=

1;p=.02;

OR=1.05

)

Cornishet

al.(2008)41

Sign

ificant

differenc

eswerefoun

dwith

regard

toma-

ternalage(F(2,1

09)=

2.50

;p<.10)

Noother

risk

factors

wereinve

stigated

Contin

ued

onnextpage

N. Vliegen et al.



014

Table6

Con

tinue

d

Results

relatin

gto

dem

ograp

hic

variab

les

Results

relatin

gto

other

risk

factors

Clin

ical

samples

Vlie

genet

al.(2010)42

Vlie

genet

al.(2013)43

Sign

ifica

ntdifferen

ceswerefoundwith

rega

rdto

finan

cial

prob

lems(69%

vs.3

1%:χ

2=4.39

;p<.05)

Current

depressedmothe

rsrepo

rted(1)moreillne

ssof

closerelatives

(100

%versus

46%:χ2

=5.21

;p<.05),(2)more-fre

quen

tmov

esfro

mon

ereside

nceto

anothe

r(92%

vs.7

3%:χ

2=2.55

(NStre

nd))&(3)m

orefreq

uent

leavingthefather

ofthech

ild(46%

versus

35%:χ

2=.49(NStren

d))

Conce

rningpersonality

factors:self-criticism

,butnotdep

enden

cy,assessed

atT1

predictedboth

dep

ressiondiagn

osis&

leve

lsofdep

ressionat

follo

w-up

HDRS,

Ham

iltonDep

ressionRatingSc

ale;

HMRA,H

ierarchical

Multip

leReg

ressionAnalysis;N

S,nonsign

ifica

nt;P

PD,p

ostpa

rtum

dep

ression;S

AS,

Spielberge

rAnxietySc

ale,

statesubscale.




Cornish and colleagues41 showed that chronically depressedmothers were slightly younger (p < .10) than mothers whohad never been depressed. Campbell and colleagues9 like-wise found that intermittently and chronically depressedmothers were significantly younger than never-depressedand remitted-depressed mothers. By comparison, seven stud-ies found no influence of the mother’s age on developmentof chronic PPD.26–29,32,33,35

SOCIOECONOMIC STATUS Of the nine studies investigatingvariables related to educational, occupational, and maritalstatus, only three found that they affected the chroniccourse of PPD. The National Institute of Child Healthand Human Development study6,9 found that chronicallydepressed women had a lower level of education and alower income-to-needs ratio than the remitted group. Atone month postpartum, mothers classified as chronicallydepressed were more likely to have no partner and no plansto go out to work. Zelkowitz and Milet27 found chroni-cally depressed mothers to be lower in occupational and ed-ucational status than the group who had remitted (p < .05).Furthermore, Horowitz and Goodman29 found a negativecorrelation between income and maternal depression scoresat four to fivemonths postpartum (p < .001). By comparison,six studies found no influence of socioeconomic status on de-velopment of chronic PPD.3,30,32,33,35,41

PARITY Of the six studies that investigated the mother’sparity, none found that it had influenced the course ofPPD.26,27,29,32,33,35

ETHNICITY Five studies investigated the possible influence ofethnicity. Howell and colleagues35 found that chronicallydepressed mothers were more frequently nonwhite thanmothers in their other three subgroups (never depressed,in remission, late onset). McMahon and colleagues40 foundthat chronically depressed mothers were more often non–English speaking. By comparison, three studies found noinfluence of ethnicity on the course of PPD.3,27,33

INFANT GENDER Of the five studies investigated the impact ofthe child’s gender, none found that it influenced the chroniccourse of PPD.26–28,35,41

Risk FactorsA number of factors in the postpartum period have beenfound to predict a chronic course of depression, and someof these factors are also known risk factors for PPD. Thesefactors can be divided into four categories, as follows:

PARTNER RELATIONSHIP AND SOCIAL SUPPORT Three studies foundthat chronically depressedmothers reported significantly less sat-isfaction with spousal support than mothers who were subclini-cally depressed and thosewhose PPD remitted.24,25,40 Two otherstudies took into account more specific aspects of the partner



N. Vliegen et al.

relationship: Blabey and colleagues33 found that a controlling,threatening partner was significantly associated with persistentPPD, and Vliegen and colleagues42,43 found a (nonsignificant)trend for chronically depressed mothers to leave the fathers oftheir children more frequently. In addition, two studies foundthat chronically depressed mothers reported receiving less socialsupport thanmotherswhose depression remitted.9,29 By compar-ison, two studies did not find that social support differentiatedbetween chronic and remitted PPD mothers.30,35

HISTORY OF MENTAL HEALTH PROBLEMS OR MORE SPECIFIC CHILD-

HOOD FEATURES Three studies found that mothers withchronic PPD were more likely to have a history of depres-sion29,35 or mental health problems,25 though two studiesfound that a history of depression24 or mental healthproblems27 did not differentiate between subgroups withdifferent courses of PPD. Buist and colleagues37,38 foundthat PPD mothers with a history of childhood sexual abusefailed to improve as much as mothers who had not beenabused. McMahon and colleagues40 reported that a historyof low maternal care during childhood was significantlyassociated with chronicity of PPD.

CONTEXTUAL RISK FACTORS A chronic course of PDD wasfound to be associated with parental stress in two studies26,29

and with financial worries in three.25,26,42,43 Howell andcolleagues35 found that chronically depressed mothers showeda smaller reduction in postpartum physical symptoms overtime compared to the remitted group. This study also showedthat the incidence of health problems in the infants, such ascolic and illness, did not differ between remitted and chronicPPD mothers. Vliegen and colleagues42,43 found that chroni-cally depressed mothers reported significantly more illnessamong close relatives and a (nonsignificant) trend of more-frequent moves from one residence to another. In two stud-ies, a composite measure of stress was used. Ashman andcolleagues3 calculated a Contextual Risk Composite Mea-sure that included stress in five domains (life events, maritaldissatisfaction, parenting, family conflict, and lack of socialsupport). A chronic course of depression was associated withhigher levels of these contextual risks. Although the studydid not examine whether contextual risk predicted achronic course of PPD, these factors were stable over time,suggesting that the subgroup of mothers with chronic, severedepression experienced repeated exposure to stressful lifecircumstances. Klier and colleagues32 computed a MultipleRisk Index including seven variables (household crowding,maternal age, problems during pregnancy, weight gain ofless than 9 kg during pregnancy, dissatisfaction with socialsupport, financial resources, and the child being unwanted).Women with two or more risk factors at birth were likelyto have stable depressive symptomatology from birth to6 months postpartum, and from 6 to 18 months; by compar-ison, the correlations among the depression measures atthese three time points were not significant for women withfewer than two risk factors.



PERSONALITY FACTORS Problems managing role demands,35

anxiety over relationships and an immature defense style,40

and high standards and excessive self-criticism42,43 havebeen found to put mothers at increased risk of developingchronic PPD.

DISCUSSION AND CONCLUSIONSThe general findings of this review of 23 longitudinal stud-ies that followed up mothers after a diagnosis of PPD canbe summarized as follows. First, the reviewed studies foundthat the severity of the depression (mean level of depres-sion) in mothers with PPD decreased at different timepoints in the postpartum period, but not always to a nonde-pressed level (below the cutoff), and that the decrease isnot always statistically significant. Second, with regard toprevalence, studies indicate that an estimated 30% of PPD-affected mothers in community samples and 50% in clinicalsamples continue to havemajor depression during their child’sfirst year of life and even beyond. Third, 12 publications dis-tinguishing between subgroups of mothers with PPD consis-tently identified (1) a chronically depressed group of motherswho continued to experience clinically elevated depressivesymptoms and (2) a remitted group of mothers who experi-enced acute major PPD but were no longer depressed atfollow-up.When severity of depressionwas also taken into ac-count, a more differentiated picture of chronic depressionemerged, with subgroups of mothers showing (1) chronic ma-jor depression, (2) stable minor depression, or (3) recurrentmajor depression without full recovery between episodes.Taken together, these studies show that mothers with PPDcannot be considered a homogeneous group. A considerableproportion of mothers who experience PPD return to the levelof depression of normal controls at four months postpartumand remain in remission throughout a long follow-up period,indicating that for these mothers, depression constitutes atime-limited problem. For a large group of mothers (38%),however, PPD is the prelude to the development of a chronicdepressive disorder. Alternatively, as discussed in more detailbelow, chronic PPD may perhaps simply be the continuationof chronic depression or dysthymia that is already present.Finally, although a minority of the studies found evidencefor sociodemographic differences (younger age of mother;lower maternal income and occupational and educationalstatus; minority/nonwhite ethnicity), results regarding thefour domains of risk factors seem to be more equivocal.More specifically, lower quality of partner relationship (withthe exception of two of nine studies that did not find socialsupport to have an influence), a history of depression, sexualabuse, or lower-quality maternal care, higher parental stressand contextual risk factors, and personality-related vulnera-bility have been consistently found to predict a chroniccourse of PPD. The incidence of infant colic and infant illnessdid not seem to differ between mothers whose PPD remittedand those whose PPD became chronic. In this regard, the




composite measures used in two studies3,32 are of major in-terest. Both measures, which included five and sevendomains of risk, respectively, revealed a chronic course of de-pression to be significantly associated with higher levels ofcontextual risk. These risk factors were stable over time,suggesting repeated or chronic exposure to stressful lifecircumstances.

LimitationsThe results of this review are subject to various limitations.No “gold standard” is available for defining and measuringPPD and its course. As a consequence, studies have useddifferent criteria to define PPD and different instrumentsto measure it at diverging time points. The large differencesbetween these studies therefore need to be discussed care-fully and critically. Of special note in this context are(1) the conceptualization of PPD and its severity and chro-nicity, (2) postpartum onset versus previous vulnerability todepression, (3) the instruments used to assess PPD and itscourse, (4) the samples investigated, and (5) the role oftreatment. Finally, we propose guidelines for designingstudies whose results would be easier to compare, whichcould lead, in turn, to a more consistent body of knowledgein this domain.

ConceptualizationThe researchwe have reviewed concerning the course of PPDis hampered by the use of differing definitions that often donot take into account that depression is a heterogeneousdisorder that ranges from mild, transitory disturbances ofmood to severe, persistent depressed mood associated withsevere social and occupational impairments.7 Hence, aclear definition of key concepts is needed that considersthe severity and course of the depression as distinct and im-portant factors, particularly since studies have often con-founded them.

With regard to the severity of depression, DSM-IV dis-tinguishes between mild, moderate, and severe depression.11

Earlier classification systems based on the Research Diagnos-tic Criteria46 distinguished between definite major depres-sion (depressed mood and five symptoms), probable majordepression (depressed mood and four symptoms), and minordepression (depressed mood and three symptoms).24

In terms of the course of depression, DSM-IV describeschronic depression as depressive symptoms persisting forat least two years, and distinguishes between differenttypes of chronic depression on the basis of the severity ofsymptoms:47 (1) chronic major depression, referring to full-blown clinical depression lasting for a minimum of twoyears; (2) recurrent major depression without complete in-terepisode recovery, in which full clinical symptoms (i.e.,meeting full DSM-IV criteria) and subthreshold symptomsalternate over a period of at least two years; and (3) dysthymia,referring to a condition characterized by depressed moodthat persists for at least two years (which is conceptualized as



a mild form of chronic depression). The Research DiagnosticCriteria diagnosis of intermittent depression is similar todysthymia as defined in DSM-IV.48 Dysthymia in combinationwith a major depressive episode is termed double depression.47

In the reviewed studies, operationalizations other thanthose described in the DSM-IV or Research Diagnostic Cri-teria are often used. In some studies, chronic depression isdefined in terms of long-lasting depressive symptoms thatare present from one follow-up period to the next, butnot necessarily over a two-year period.27,32 However, in-vestigation of the course of PPD by the use of differentfollow-up points makes it difficult to distinguish betweenchronic depression and recurrent, or episodic, depressionas a discrete acute episode of depression after a symptom-free period.7 Furthermore, it is hard to detect whether de-pression is actually chronic, with depressive symptomscontinuing from one follow-up period to the next, whenonly a fewmeasurements are made at points over an extendedperiod of time. If the follow-up points are spread out, it maynot be possible to identify shorter-term changes in thecourse of the PPD. In this regard, some authors stress theimportance of assessing depression in the interval betweenthe study’s established time points for measurement.3,47

PPD Onset Versus Previous VulnerabilityMost of the studies examining the course of PPD start tolook at depressive symptomatology from childbirth on,partly guided by the postpartum-onset specifier of fourweeks postpartum described in the DSM-IV-TR. In thestudies that we reviewed, none examined whether PPDamong the sample could actually be an extension of de-pression with onset during or before pregnancy. The timeof onset of “postpartum” depression has, in fact, been fre-quently debated in the literature.49,50 Some authors evenquestion whether PPD should be considered as a specificentity.51 These authors argue that being pregnant and giv-ing birth to a child are major stressors that may lead to anew, or even the first, episode of depression in womenwho are vulnerable for this disorder. Of course, even thenthe term postpartum depression seems justified, as depres-sion in early motherhood is characterized by many specificfeatures such as being preoccupied with worries aboutthe baby’s well-being and about one’s own abilities asa mother. Jones and Cantwell52 similarly recommend thecontinued use of a pregnancy and postpartum onset speci-fier in each category of mood disorder in DSM-5.53 Never-theless, studies suggesting that 11.5%50 and even up to50%49 of depressed women report depression onset beforeor during pregnancy point to the importance of assessingdepression, as well as the vulnerability to depression, be-fore the postpartum period. Congruent with these views,DSM-5 has extended the PPD specifier to include depres-sive symptoms occurring during pregnancy.

Only five studies covered in the present review investi-gated a history of depression among participants (as



N. Vliegen et al.

discussed above), and three of them found such a history tobe a possible risk factor for chronic PPD.25,29,35 Conse-quently, we have only limited knowledge about how PPDmight be a recurrence of a preexisting disorder in a subsetof women. Furthermore, none of the studies specifically in-vestigated prenatal onset of depression as a possible factorheightening the risk of a chronic course of PPD. Stowe andcolleagues50 therefore correctly argue that the heterogene-ity of previous depression histories in samples of chroni-cally depressed PPD women may explain the limitedsuccess of existing efforts to identify the risk factors forchronic PPD. This situation illustrates a disadvantage of adisorder-centered approach to the study of depression—an approach that tends to focus on the onset and courseof specific disorders (such as PPD).54 By contrast, a devel-opmental, person-centered approach—one that followswomen, over time, during the transition to motherhood—may be more appropriate and may yield important newinsights into the nature of PPD.55

The current review therefore cannot draw conclusionsregarding the association between the onset (prenatal orpostpartum) of depression and its course, although thefew existing studies suggest that, at least in a subsampleof women, chronic PPD may be an extension of previousepisodes of depression and thus probably reflects a nonspe-cific vulnerability to depression.

Instruments UsedDifferent self-report instruments have been used to assessPPD symptoms, whereas various clinical interviews havebeen used to diagnose PPD as a syndrome. Studies suggestthat these various instruments and clinical assessmentsmay result in considerable differences between findings,depending on the instruments/assessments and cutoffs thatare used.

QUESTIONNAIRES In empirical research, questionnaires arefrequently used to assess the occurrence and severity ofPPD. These include the HDRS,56 Beck Depression Inven-tory (BDI, BDI-II),57,58 General Health Questionnaire,59

Center for Epidemiological Studies Depression Scale,60

Comprehensive Psychiatric Rating Scale,61 EdinburghPostnatal Depression Scale (EPDS),62 Postpartum Depres-sion Screening Scale,63 and Patient Health Questionnaire.64

These measures are also often used to define clinical de-pression using a cutoff score. In studies using the Centerfor Epidemiological Studies Depression Scale, for instance,individuals scoring 16 or higher are commonly categorizedas clinically depressed,3,9,28,31,34,41,60 and different cutoffscores are often used to distinguish between different levelsof severity. According to the scoring guidelines for the BDI,for example, a score of 11 is the lowest score for mild tomoderate depression, whereas a score of 19 indicates themoderate-to-severe range.65 In the BDI-II, total scoresranging from 0 to 13 represent “minimal” depression, 14



to 19 “mild,” 20 to 28 “moderate,” and 29 to 63 “severe”depression.58 EPDS scores exceeding a threshold score of10 (within family medical practices when used for screen-ing purposes) and 12 (within research studies) indicate agreater likelihood of depression.62

Potential methodological problems that are associatedwith the use of cutoff scores66 are the instruments’ lowersensitivity (i.e., the number of women who are correctly di-agnosed as depressed) and specificity (i.e., the number ofwomen who are correctly diagnosed as not depressed).First, in several self-report instruments that were not specif-ically developed for assessing PPD, high scores (e.g., on theBDI) may reflect fatigue, low levels of bodily satisfaction,and loss of libido, which are all considered normal in thepostpartum period. Self-report measures such as the EPDSwere developed specifically for use within a postnatalpopulation and take into account that these symptomsare common in the postpartum period. However, a meta-analysis reports that, whereas the specificities of the BDI,EPDS, and Postpartum Depression Screening Scale areall relatively high and similar, the sensitivity of theseinstruments varies considerably, with the latter two beingmore sensitive.67

Second, different cutoff scores have been used in differ-ent studies, making it difficult to compare results acrossstudies. In defining clinical thresholds, studies have usedBDI scores of �12,68 �17,39 and �23,38 and BDI-II scoresof �13,42,43 and �14.29 For the HDRS, Buist and Janson38

used a cutoff of �15. For the EPDS, studies have used cut-off points of �9,30,68 �10,27,29,36 >12,8,18,39�12,23,26,69 and�13.70 See also in this context Matthey and colleagues’ re-view71 of several validation studies using the EPDS;62,72–74

in discussing the use of “validated” versus “unvalidated”cutoff scores, the authors suggest that using validated cut-off scores of 13 for major depression and 10 for minor de-pression represents an optimal balance between sensitivityand specificity.

A final concern with regard to cutoff values relates tocultural differences. The prevalence of PPD,68 the expres-sion of depressive symptoms,75 and the sensitivity andspecificity of measures such as the EPDS71,76 vary amongdifferent cultures. Consequently, the cutoff values validatedin particular English-speaking populations cannot neces-sarily be generalized to other countries or cultures.

CLINICAL INTERVIEWS Numerous standardized clinical inter-views have been used in studies examining the course ofPPD: Goldberg’s Standardized Psychiatric Interview,77 PresentState Examination,78 Montgomery–Asberg Depression RatingScale,79 Schedule for Affective Disorders and Schizophrenia–Lifetime,16 Diagnostic Interview Schedule III–Revised,80

Structured Clinical Interview for DSM-III-R and DSM-IV,81

and Composite International Diagnostic Interview.82

Although interviews may be more reliable than ques-tionnaires, self-report measures are easier and less costly




to administer and do not require trained interviewers,which may explain their greater popularity, particularlyin studies with large samples. Affonso and colleagues68

state that questionnaire data should be used to analyzewomen’s experiences of depressive symptoms but not todiagnose clinical depression, for which clinical interviewsare necessary.

Another limitation of the reviewed studies is that theyvaried in sampling procedures, leading to samples beingrecruited from different populations of depressed indi-viduals, including hospital patients, psychiatric clinic out-patients, clients of social service agencies, and people inthe community. Some results are based on very smallsamples,27,32 making it hard to generalize findings. Further-more, the results from studies using community samplescannot simply be generalized to clinical populations. Giventhat few studies to date used clinical samples (n = 5) andthat some studies included mothers with heterogeneousdiagnoses,27 it is difficult to draw conclusions about thespecific postpartum depressed group.

The Role of TreatmentThe heterogeneity of PPD makes it difficult to assess treat-ment. In two of the studies with nonclinical samples,23,36

and in all five studies with clinical samples,37–39,42,43 themothers received some kind of support or treatment, butit is difficult to determine whether recovery occurred be-cause of treatment or other factors.

Two studies examined the effect of supportive counsel-ing on the course of PPD in nonclinical samples andshowed that the prevalence of depression at one-year fol-low up was lower in participants who received the inter-vention than in those who did not (15% vs. 32%;36

31% vs. 62%23).

RECOMMENDATIONS FOR FUTURE RESEARCH ANDCLINICAL INTERVENTIONSIn this section, we outline a number of recommendations forfuture research and intervention based on the above review.

First, future research should replicate published findingsusing larger samples, in a variety of clinical contexts, withan exclusive focus on mothers with PPD.

Second, the considerable heterogeneity in the conceptu-alization of PPD should be addressed. In order to obtain asystematic body of research on PPD and its course, studiesshould use more common, internationally agreed criteria; vali-dated cutoff scores for instruments; more consistent and paral-lel procedures; and comparable measurement time points.With regard to this last category, future studies of PPD shoulddefine clear time points for assessing patients, assess depres-sive symptoms between these measurement points, and col-lect data on subclinical depressive symptomatology. Thenew definitions and criteria in DSM-5 represent an impor-tant step in this direction.



Third, congruent with a person-centered approach—andfollowing the recommendations of several researchers inthe field83 who advocate a move beyond thinking of PPDas applying solely to the postpartum period—future re-search should investigate mothers’ history of depression,as well as possible risk and protective factors, before deliv-ery. A possible method for taking into account the onsetand timing of depressive symptoms, treatment, and lifeevents is the life history calendar84,85 method, which isdesigned to collect detailed, individual-level event timingand sequencing data within an interview framework. Withthis method, it is easy to obtain information on mothers’history of depressive episodes, including any current de-pression (onset, timing, and duration), on important lifeevents, and on treatments received (see Vliegen et al.).42,43

In this regard, we recommended the use of compositemeasures that take into account several domains of con-textual risk.3,32

Fourth, this review stresses the need for culturally sensi-tive studies investigating different racial and ethnic groups,and the need to consider other demographic variables suchas socioeconomic status.13

Finally, studies should take into account individual per-sonality factors that may influence the treatment-seekingpatterns of mothers with PPD. We need more systematic,theory-driven research concerning the psychosocial42,55

and biological factors54 that may function, either sepa-rately or together, as either risk or protective factors inthe development of PPD.

With regard to clinical implications, professionals shouldbe aware that the onset of PPD is often before the post-partum period and that PPD can persist far beyond the firstyear after childbirth. Clinicians who treat PPD mothersneed to be well informed about the prognosis and the differ-ent possible trajectories of the depression. Whereas forsome mothers recover from their depressive symptomsfairly quickly, other mothers’ experience of PPD signalsthe start of what proves to be a chronic disease, with con-siderable implications for the mother, child, and broaderfamily. Consequently, programs specifically designed forPPD mothers need to include follow-up assessments inorder to identify risk factors for the depression becomingchronic. Furthermore, clinicians need to be aware thatmothers’ previous episodes of depression and that possiblecontextual factors heighten vulnerability for a chroniccourse of depression.

In sum, families with mothers suffering from PPD needthe engagement of clinicians who are sensitive to the signsthat the depression may become chronic. Moreover, giventhat parental depression has a detrimental (and poten-tially long-term) influence on the development of children,parents need ongoing contact with clinicians who aremindful of the parent-child interaction as well as of eachchild’s need for developmental support during early child-hood and beyond.



N. Vliegen et al.

Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the contentand writing of the article.

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