Influences of maternal postpartum depression on fathers and on father–infant interaction

Maternal postpartum depression (PPD) has been shown to negatively influence mother–infant interaction; however, little research has explored how fathers and father–infant interaction are affected when a mother is depressed. This study examined the influence of maternal PPD on fathers and identified maternal and paternal factors associated with father–infant interaction in families with depressed as compared with nondepressed mothers. A convenience sample of 128 mother–father–infant triads, approximately half of which included women with significant symptoms of PPD at screening, were recruited from a screening sample of 790 postpartum women. Mothers and fathers completed measures of depression, marital satisfaction, and parenting stress at 2 to 3 months' postpartum and were each videotaped interacting with their infants. Results indicate that maternal PPD is associated with increased paternal depression and higher paternal parenting stress. Partners of depressed women demonstrated less optimal interaction with their infants, indicating that fathers do not compensate for the negative effects of maternal depression on the child. Although mother–infant interaction did not influence father–infant interaction, how the mother felt about her relationship with the infant did, even more so than maternal depression. The links between maternal PPD, fathers, and father–infant interaction indicate a need for further understanding of the reciprocal influences between mothers, fathers, and infants.     

Maternal depression: A review of relevant treatment approaches for mothers and infants

The negative impact of postpartum depression on the mother‐infant relationship and infant development more generally has been well documented. Compared to infants of nondepressed mothers, infants of depressed mothers have been shown to be less securely attached to their caregivers and often have cognitive, emotional, and behavioral deficits that persist well into childhood. Recent evidence has suggested that reduction of maternal depressive symptoms may itself not be sufficient to prevent negative effects on children. Rather, treatments that target the mother‐infant relationship may have great potential in providing a buffer against the potentially damaging effects of postpartum depression. Based on our review of several treatment‐outcome studies, we conclude that mother‐infant psychotherapies and home‐based interventions are generally efficacious in their goal of ameliorating detrimental consequences for children of depressed mothers. Nonetheless, the field must continue to investigate the extent to which treatment gains are maintained over time and the mechanisms by which protective effects occur. It is likely that the most efficacious treatment approaches will be those that address the needs of the mother, the infant, and their relationship.     

The impact of prenatal serotonin reuptake inhibitor (SRI) antidepressant exposure and maternal mood on mother–infant interactions at 3 months of age

Exposure to maternal depression increases risks for altered mother–infant interactions. Serotonin reuptake inhibitor (SRI) antidepressants are increasingly prescribed to manage antenatal maternal illness. The impact of SRIs on early mother–infant interactions was unknown. Three-month-old infants of 32 depressed mothers treated with SRI medications during pregnancy and 43 non-medicated mothers were studied. Using an established face-to-face mother–infant interaction paradigm, dyad interactions were studied with and without a toy. Videotaped sessions yielded 4 measures: maternal sensitivity, dyadic organization, infant readiness to interact, and maternal interruptive behaviors. Even with prenatal SRI treatment, depressed mothers interrupted their infants more during toy play. In the absence of prenatal SRI treatment, maternal postnatal depression adversely influenced infant behavior. Higher levels of maternal depression symptoms at 3 months predicted poorer infant readiness to interact during the toy session. Conversely, in the SRI-exposed group, higher prenatal depression scores predicted greater infant readiness to interact at 3 months. Increased infant readiness with SRI exposure suggests a “fetal programming effect” whereby prenatal maternal mood disturbances shaped a future response to a postnatal depressed maternal environment.     

Individual differences in non-clinical maternal depression impact infant affect and behavior during the still-face paradigm across the first year

Maternal depression can significantly impact mothers’ sensitivity to their infants’ needs as well as infants’ social and emotional development. The still-face paradigm (SFP) is widely used to assess infants’ understanding of the contingency between their own behavior and that of their caregivers, as well as infants’ ability to self-regulate arousal levels during sudden changes in maternal responsiveness. Infants of clinically depressed mothers display blunted levels of negative affect compared to infants of non-depressed mothers during the still-face (SF) phase. However, little is known about whether individual differences in elevated, non-clinical levels of maternal depression similarly affect mother-infant interactions. The current study examines the longitudinal effects of non-clinical maternal depression on infant and maternal behaviors during the SFP. Infants (N = 63) were assessed at 5 and 9 months and maternal depression was assessed at 5 months using the Beck Depression Inventory (BDI). Infants of mothers with elevated levels of depression displayed less negative engagement during the SF phase compared to infants of mothers with lower levels of depression. This effect was present at 5 months, but not at 9 months. Findings demonstrate that non-clinical levels of maternal depressive symptomatology can have a significant impact on infants’ affective regulation during the first half of the first year of life, but this does not necessarily have a long-lasting influence later in infancy. Interventions may want to target mothers with non-clinical depression to promote healthy infant social and emotional development.     

Prenatal depression effects and interventions: A review

This review covers research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity and low birthweight. Although prenatal depression and cortisol were typically measured at around 20 weeks gestation, other research suggests the stability of depression and cortisol levels across pregnancy. Women with Dysthymia as compared to Major Depression Disorder had higher cortisol levels, and their newborns had lower gestational age and birthweight. The cortisol effects in these studies were unfortunately confounded by low serotonin and low dopamine levels which in themselves could contribute to non-optimal pregnancy outcomes. The negative effects of depression and cortisol were also potentially confounded by comorbid anxiety, by demographic factors including younger age, less education and lower SES of the mothers and by the absence of a partner or a partner who was unhappy about the pregnancy or a partner who was depressed. Substance use (especially caffeine use) was still another risk factor. All of these problems including prenatal depression, elevated cortisol, prematurity and low birthweight and even postpartum depression have been reduced by prenatal massage therapy provided by the women's partners. Massage therapy combined with group interpersonal psychotherapy was also effective for reducing depression and cortisol levels. Several limitations of these studies were noted and suggestions for future research included exploring other predictor variables like progesterone/estriol ratios, immune factors and genetic determinants. Further research is needed both on the potential use of cortisol as a screening measure and the use of other therapies that might reduce prenatal depression and cortisol in the women and prematurity and low birthweight in their infants.     

Interactions between depressed and nondepressed Latina mothers and their premature infants

The impact of depression upon mother–infant interaction was studied longitudinally in a sample of very low income, immigrant Latina mothers with premature, very low birth weight infants. Both maternal characteristics and infant characteristics were examined using a rating scale which measured feeding interactions. Results indicate that mothers who were depressed at one month did not interact differently with their premature infants than nondepressed mothers. In addition, infants of mothers who were depressed at one month did not interact differently with their mothers than infants of nondepressed mothers. There were no differences between groups of mothers who remained depressed across the one-year period and groups whose scores reflected no depression or changes in depression levels. These findings challenge previous assumptions about interactions between depressed mother–infant dyads. Results indicate the need to broaden study attention to include socioeconomic, cultural, and life circumstances of families that may have greater impact on child outcomes than single assessments of maternal depression. Such studies may lead to changes in the way services are delivered and the types of interventions provided to non-mainstream families. © 1997 Michigan Association for Infant Mental Health     

Infants of “depressed” mothers interact better with their nondepressed fathers

To determine whether infants of “depressed” mothers interact better with their nondepressed fathers, twenty-six 3- to 6-month-old infants were videotaped during face-to-face interactions with their parents. The “depressed” mother group consisted of twelve 3- to 6-month-old infants and their “depressed” mothers and nondepressed fathers. The control group was composed of 14 nondepressed mothers and nondepressed fathers and their 3- to 6-month-old infants. In the “depressed” mother group, the nondepressed fathers received better interaction ratings than the “depressed” mothers. In turn, the infants received better interaction ratings when they interacted with their nondepressed fathers than with their “depressed” mothers. In contrast, nondepressed fathers and mothers and their infants in the control group did not differ on any of their interaction ratings. These findings suggest that infants' difficult interaction behaviors noted during interactions with their “depressed” mothers may not extend to their nondepressed fathers. The data are discussed with respect to the notion that nondepressed fathers may “buffer” the effects of maternal depression on infant interaction behavior.     

Maternal postpartum depression is a risk factor for infant emotional variability at 4 months

Maternal postpartum depression (PPD) is a risk for disruption of mother–infant interaction. Infants of depressed mothers have been found to display less positive, more negative, and neutral affect. Other studies have found that infants of mothers with PPD inhibit both positive and negative affect. In a sample of 28 infants of mothers with PPD and 52 infants of nonclinical mothers, we examined the role of PPD diagnosis and symptoms for infants’ emotional variability, measured as facial expressions, vocal protest, and gaze using microanalysis, during a mother–infant face-to-face interaction. PPD symptoms and diagnosis were associated with (a) infants displaying fewer high negative, but more neutral/interest facial affect events, and (b) fewer gaze off events.  PPD diagnosis, but not symptoms, was associated with less infant vocal protest. Total duration of seconds of infant facial affective displays and gaze off was not related to PPD diagnosis or symptoms, suggesting that when infants of depressed mothers display high negative facial affect or gaze off, these expressions are more sustained, indicating lower infant ability to calm down and re-engage, interpreted as a disturbance in self-regulation. The findings highlight the importance of not only examining durations, but also frequencies, as the latter may inform infant emotional variability.     

Infant sensitivity to negative maternal emotional shifts: Effects of infant sex,maternal postnatal depression,and interactive style

This study examined the effects of infant sex, maternal postnatal depression, and maternal interactive style on infant sensitivity to maternal negative emotional shifts. Face‐to‐face interactions of 68 mother–infant dyads were analyzed at 8 and 18 weeks. Twenty‐five (28%) mothers had postnatal depression. Interactions were analyzed in terms of overall maternal interactive style: “sensitive,” “anxious,” “intrusive,” and “sad.” Episodes of negative shifts in maternal emotional expression were recorded, along with expressions of infant sensitivity to these changes. Daughters of depressed mothers showed higher rates of sensitivity to maternal negative emotion whereas their sons showed lower rates, in comparison to both girl and boy infants of well mothers. While maternal interactive style had no effect on 8‐week infant sensitivity to maternal negative emotional shifts, high rates of 18‐week infant sensitivity were predicted by both an 8‐week and a concurrent, “sad” maternal interactive style. The findings are discussed in relation to theories of emotional and interpersonal development.     

Effects of maternal depression in the Still-Face Paradigm: A meta-analysis

The Still-Face Paradigm (SFP) enables researchers to examine the quality of mother-infant interactions. In typical infants, a classic still-face effect (SFE) has been confirmed whereby infants demonstrate reduced positive affect (PA), reduced gaze (GA), and increased negative affect (NA). Recently, the SFP has been used to examine the effect of maternal depression upon infant behaviour. However, the nature and consistency of the behavioural responses of infants of depressed mothers during the SFP remains unclear. In the current meta-analysis, we examined whether or not infants of depressed mothers demonstrate the classic SFE, as well as whether or not these infants display the same levels of PA, NA, and GA as their counterparts with non-depressed mothers. Results revealed that infants of depressed mothers display the classic SFE like infants of their non-depressed counterparts. However, infants of depressed mothers also demonstrated significantly higher levels of PA during the still-face episode. One potential interpretation of this finding is that infants prior experience of similar, depressed interactions with their mothers, encourages them to amplify their positive attachment signals in order to engage maternal attention and response. Alternatively, or additionally, infants of depressed mothers could be using PA in order to regulate their own NA.     

Cardiac disorders and antidepressant medications

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have been associated with an increase in cardiovascular disorders, especially in depressed patients who have pre-existing cardiac disease. These disorders are less likely to occur when a therapeutic dosage is administered. Injuries because of falls are more likely in elderly depressed patients, and orthostatic hypotension occurs with the use of TCAs. Selective serotonin reuptake inhibitor (SSRI) antidepressants differ structurally and in side effects from TCAs and MAOIs. They appear to be effective for treatment of depression, and their side-effect profiles appear safer than those of earlier approved antidepressants used by depressed patients with cardiovascular disorders.     

Cardiac Disorders and Antidepressant Medications

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have been associated with an increase in cardiovascular disorders, especially in depressed patients who have pre-existing cardiac disease. These disorders are less likely to occur when a therapeutic dosage is administered. Injuries because of falls are more likely in elderly depressed patients, and orthostatic hypotension occurs with the use of TCAs. Selective serotonin reuptake inhibitor (SSRI) antidepressants differ structurally and in side effects from TCAs and MAOIs. They appear to be effective for treatment of depression, and their side-effect profiles appear safer than those of earlier approved antidepressants used by depressed patients with cardiovascular disorders.     

The mediating role of maternal responsiveness in some longer term effects of postnatal depression on infant development

We hypothesized a mediating role for low maternal responsiveness in certain child developmental deficits found previously to be associated with postnatal depression. Forty depressed inpatients and 48 control (non-depressed) mothers and their infants were followed until 42 months postpartum. Mother–infant interactions were impaired at 6 months postpartum in the depressed group. Subsequent cognitive deficits were found in children's Full Scale IQ on the Wechsler Preschool Primary Scale of Intelligence (Revised) at 42 months of age. Statistical modeling of the mediation hypothesis confirmed that these effects were overwhelmingly explained by lowered maternal responsiveness at 6 months. Similarly, increased temperamental difficulties were apparent in children of depressed mothers but were not correlated with maternal responsiveness. Male infants of depressed mothers were disproportionately vulnerable (compared to females) to impaired cognitive abilities associated with maternal depression. The data concur with previous work and provide empirical support for the theoretical prediction that early disturbances of the mother–infant interaction will mediate some developmental deficits in the children of depressed mothers.     

THE IMPACT OF DEPRESSION ON MATERNAL RESPONSES TO INFANT FACES IN PREGNANCY

Research has suggested that prenatal depression may be associated with disrupted maternal responses to infant stimuli, with depressed pregnant women not showing the bias toward distressed infants as that observed in nondepressed pregnant women. The current study examined the effects of depression on self‐ reported responses to infant stimuli, in early pregnancy. Women with clinical depression (n = 38), and nondepressed women (n = 67) were recruited from a wider cognitive behavioral therapy trial. They completed Maternal Response Scales in which they were presented with images of distressed, neutral, and happy infant faces, with no time limit. The women rated their responses to these images along three dimensions—wanting to comfort, wanting to turn away, and feelings of anxiety—using Likert scales via a computerized task. There was evidence that women with depression in pregnancy showed different responses than did women without depression. Women with depression were substantially more likely to be in the highest quartile for ratings of wanting to turn away, odds (OR) ratio = 4.15, 95% confidence intervals (CIs) = 1.63–10.5, p = .003, and also were substantially less likely to be in the highest quartile for wanting to comfort a distressed infant face, OR = 0.22, 95% CIs = 0.09–0.54, p < .001. Findings are consistent with there being both a heightened avoidant and a reduced comforting response toward distressed infants in depressed pregnant women, providing some support that depression disrupts maternal preparations at a conscious level.     

Caregiving behavior and interactions of prenatally depressed mothers (antidepressant‐treated and non‐antidepressant‐treated) during newborn acute pain

This exploratory study aimed to examine time‐based measures of the behaviors and interactions of prenatally depressed serotonin reuptake inhibitors (SRI)‐medicated mothers to their infant's pain (n = 10) by comparing them with similar measures obtained from prenatally depressed nonmedicated mothers and their infants (n = 10), and nondepressed mothers and their infants (n = 10). During the second trimester of their pregnancy, the 30 study mothers were assessed for depression and anxiety, with no further measures of maternal mood taken. Maternal and infant interactions were continuously videorecorded while the infant underwent a scheduled heel lance for routine blood screening that occurred when study infants were between the ages of 24 and 60 hr. Maternal behavior and infant cry, for all 30 cases, were coded second‐by‐second for the full duration of each infant's heel lance using a reliable coding system and analyzed using odds ratio and regression analyses. Infants exposed to prenatal SRIs and depressed maternal mood were more likely to have lower Apgar scores and to exhibit weak and absent cry. Even when duration of the heel lance was controlled for, women with depression during the second trimester were more likely to exhibit depressed behavior at 2 days' postpartum despite sustained SRI antidepressant treatment. Both groups of prenatally depressed mothers were more likely to exhibit diminished response to their infants' pain cue although nonmedicated mothers' expressions of depressed behavior were more similar to healthy controls. Comprehensive understanding is essential to optimize the clinical care of mothers and their infants in this complex setting. This study contributes preliminary new findings that warrant prospective and longitudinal studies to clarify further the impacts of prenatal SRI and maternal mental mood (e.g., chronic depression and anxiety) effects on the mother–infant interaction and infant pain and stress reactivity.     

Postpartum maternal mood,feeding practices,and infant temperament in Barbados

Maternal mood, infant feeding practices, and infant temperament, using the Carey-R scales, were assessed in 226 healthy, well-nourished Barbadian mothers and their infants during the first 6 months of life. Maternal moods were assessed by self-report using the Zung depression and anxiety scales and a morale scale. Even after correcting for background variables, maternal depression and anxiety ratings and reports of despair at 6 months postpartum were significantly associated with infant temperament ratings at 6 months, using the original Carey-R scales, with factors derived from principal components analysis of the Carey items, and with summary difficulty scores. Maternal depressive symptoms were associated with decreased infant adaptability, reduced approach, negative mood and an increased sensory threshold. Infants of depressed and anxious mothers were more resistant to change and preferred constancy. These significant relationships were linear across the range of maternal mood scores and were not limited to diagnosed cases of depression or anxiety. In contrast, feeding practices were not significantly correlated with infant temperament, although infant difficulty on the temperament scales was associated with an increase in difficult feeding behaviors and with fathers’ involvement in the feeding of their infants. We conclude that interventions focused on improving maternal mood in the postpartum period are likely to impact positively upon maternal perceptions of their infants, with implications for improving child behavioral development and health in this underserved population.     

The impact of postpartum depressed mood on mother-infant interaction: Like mother like baby?

The purpose of this study was to test the hypothesis that mothers with depressed mood would exhibit less optimal interaction than their nondepressed counterparts and that their infants would show similar deficits in interactional behavior. Twenty-two mothers and their 2-month-old infants were videotaped in to-minute free-play segments in a laboratory playroom, and their interactions were coded using both time-sampling and global clinical ratings of behavior. Mothers with depressed mood were judged significantly lower on overall positive interaction, Expressivity/Affective Involvement, and Responsivity/ Sensitivity than were nondepressed mothers. Infants of mothers with depressed mood were rated significantly lower than infants of nondepressed mothers on corresponding interaction domains. Mothers with depressed mood were also rated as more variable than nondepressed mothers along a continuum of withdrawal to controlling/intrusive behavior. Contrary to prediction, level of maternal stimulation and infant activity did not differ as a function of depression in maternal mood. We conclude that mild to moderate symptoms of maternal depression may have salient but selective effects on mother-infant interaction.     

Effects of maternal postpartum depression in a well‐resourced sample: Early concurrent and long‐term effects on infant cognitive,language, and motor development

This study examined early and long‐term effects of maternal postpartum depression on cognitive, language, and motor development in infants of clinically depressed mothers. Participants were 83 mothers and their full‐term born children from the urban region of Copenhagen, Denmark. Of this group, 28 mothers were diagnosed with postnatal depression three to four months postpartum in a diagnostic interview. Cognitive, language, and motor development was assessed with the Bayley Scales of Infant and Toddler Development third edition, when the infants were 4 and 13 months of age. We found that maternal postpartum depression was associated with poorer cognitive development at infant age four months, the effect size being large (Cohen's d = 0.8) and with similar effects for boys and girls. At 13 months of age infants of clinical mothers did not differ from infants of non‐clinical mothers. At this time most (79%) of the clinical mothers were no longer, or not again, depressed. These results may indicate that maternal depression can have an acute, concurrent effect on infant cognitive development as early as at four months postpartum. At the same time, in the absence of other risk factors, this effect may not be enduring. The main weaknesses of the study include the relatively small sample size and that depression scores were only available for 35 of the non‐clinical mothers at 13 months.     

Should We Treat Depression with drugs or psychological interventions? A Reply to Ioannidis

We reply to the Ioannidis's paper "Effectiveness of antidepressants; an evidence based myth constructed from a thousand controlled trials." We disagree that antidepressants have no greater efficacy than placebo. We present the efficacy from hundreds of trials in terms of the percentage of patients with a substantial clinical response (a 50% improvement or more symptomatic reduction). This meta-analysis finds that 42-70% of depressed patients improve with drug and 21%-39% improve with placebo. The response benefit of antidepressant treatment is 33%-11% greater than placebo. Ioannidis argues that it would be vanishingly smaller because systematic biasing in these clinical trials would reduce the drug-placebo difference to zero. Ioannidis' argument that antidepressants have no benefit is eroded by his failures of logic because he does not present any evidence that there are a large number of studies where placebo is substantially more effective than drug. (To reduce to zero, one would also have to show that some of the unpublished studies find placebo better than drug and have substantial systematic or methodological bias). We also present the empirical evidence showing that these methodological concerns generally have the opposite effect of what Ioannidis argues, supporting our contention that the measured efficacy of antidepressants likely underestimates true efficacy. Our most important criticism is Ioannidis’ basic underlying argument about antidepressants that if the existing evidence is imperfect and methods can be criticized, then this proves that antidepressant are not efficacious. He presents no credible evidence that antidepressants have zero effect size. Valid arguments can point out difficulties with the data but do not prove that a given drug had no efficacy. Indeed better evidence might prove it was more efficacious that originally found. We find no empirical or ethical reason why psychiatrists should not try to help depressed patients with drugs and/or with psychotherapeutic/behavioral treatments given evidence of efficacy even though our treatment knowledge has limitations. The immense suffering of patients with major depression leads to ethical, moral, professional and legal obligations to treat patients with the best available tools at our disposal, while diligently and actively monitoring for adverse effects and actively revising treatment components as necessary.     

Pharmacotherapy of seasonal affective disorder

Seasonal affective disorder is a common variant of recurrent major depressive disorder or bipolar disorder. Treatment with bright artificial light has been found to be effective in this condition. However, for patients who do not respond to light therapy or those who lack compliance, conventional drug treatment with antidepressants also has been proposed. Substances with selective serotonergic or noradrenergic mechanisms should be preferred over older antidepressants. Although there are a number of open and controlled studies evaluating different compounds, these studies were often limited by relatively small sample sizes. Furthermore, there are no studies specifically addressing bipolar seasonal depression. This article will review the published literature on pharmacotherapy of seasonal affective disorder.