Journalof Psychosomatic Research,Vol. 20, pp. 605 to 610. PergamanPress,1976. Printedin Great Britain
A POSSIBLE RELATIONSHIP BETWEEN ANXIETY IN PREGNANCY AND PUERPERAL DEPRESSION RUSSELL
MEARES*,
JAMES GRIMWADE?
and
CARL
WOOD
1
(Received 8 December 1975) MUCH
evidence indicates that depression is common during the post-partum period [l] but is unusual in pregnancy, when suicide rates fall [2]. On the other hand, scales which correlate with subjective anxiety suggest that anxiety may be high during pregnancy, but return to normal levels during the post-partum period [3, 41. A possible relationship between anxiety in pregnancy and depression in the puerperium is suggested by the work of Tod [S]. He studied 700 consecutive pregnancies and remarked that “mild anxiety was encountered in very many pregnancies” and that “similarly, a mild form of depression was common three or four days after delivery” . . . “These minor disturbances were accepted as normal accompaniments of pregnancy and parturition”. In addition, he found 20 cases of puerperal depression, which was heralded in each case by pathological anxiety during pregnancy. Other studies indicate that depression itself, when experienced in pregnancy, is not predictive of post-partum depression [e.g. 61. In Tad’s study, however, the determination of anxiety was of dubious reliability. Tod stated that some of the pregnant women destined for puerperal depression “appeared in the best of physical and mental health, and only exhaustive probing revealed their underlying distress”. We have used objective measures in order to test the possibility that the highest levels of anxiety in pregnancy may predict the most profound forms of depression during the puerperium. METHOD The patients came from a sample of 129 married women attending an antenatal clinic at the Queen Victoria Hospital. Patients are randomly allocated to various clinics on application to the hospital, and the patients selected to enter the investigation were those who arrived for their first antenatal visit at a standard time on a particular day in consecutive weeks. Those patients whose native language was not English were excluded. No patient was rejected on other grounds and none refused to co-operate. A number of clinical details, which included a brief consideration of the patient’s sexual life, were taken. Social class was estimated by standard means, using the husband’s occupation [7]. All patients filled out the Taylor Manifest Anxiety Scale [8], which is regarded as a valid and reliable measure of anxiety [9]. A score for neuroticism was also obtained using the Eysenck Personality Inventory [lo], a widely used and well validated instrument. Neuroticism is generally conceived as having its basis in anxiety, and there is a high correlation between the two scales [Ill. In a series of 20 normal subjects, and in another of 10 patients with an anxiety state, the correlations between the two measures were 0.81 and 0.89 respectively [12]. The neuroticism scale is theoretically considered to reflect an enduring persona!ity constant which may have a biological basis. The same suggestion has also been applied to the Taylor Manifest Anxiety Scale [ll]. Certain evidence suggests, however, that the scores change significantly with changing states of depression and anxiety [e.g. 13, 141. We have therefore supposed that both scales reflect enduring personality traits and also mutable emotional states. The scales have been chosen since a previous study [15] using a questionnaire ostensibly measuring both states and traits of anxiety [16] proved unsatisfactory. Details of each woman’s labour, delivery, and whether she breast fed, were taken from the clinical notes. In order to gain adequate co-operation from the patients, it was necessary to devise a method of estimating post-partum depression which was neither tiresome nor time-consuming. The post-partum period was considered to last six months, so that six to 18 months following the birth of their child, the patients were posted a questionnaire which was largely composed of visual analogue scales for scoring depression [17]. These have been found to correlate with other standard methods of rating *Reader in Psychiatry, University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia. tFirst Assistant (Part Time), Department of Obstetrics & Gynaecology, University of Melbourne. $Professor and Chairman, Department of Obstetrics & Gynaecology, Monash University, Clayton, Victoria, Australia. 605
606
RUSSELLMEARES,JAMESGRIMWADEand CARL WOOD
depression such as the Zung and Hamilton Scales [18]. Nevertheless, the previously used visual analogue scales indicate mood change alone. The exhibition of misery or sadness is not generally considered sufficient for the clinical diagnosis of depression, which requires, in addition, evidence of hopelessness, guilt, and self-depreciation. Thus, the single measure of mood change is likely to correlate with depression but will not isolate it. We therefore used four scales. Four statements were placed above 4 lines, each 12 cm long, and on which were written, “Not at all” at one end, and “Nearly al! the time” at the other. The statements were: “I felt miserable and depressed”, “I had spells of crying”, “I felt without hope “, “I felt useless and a burden to others”. The last statement was taken to reflect minor guilt and loss of self-esteem. The patient was asked to make a cross on each line, so as to indicate how she felt following the birth of her baby. Following this, she was asked, if she had been depressed, to indicate the length of her depression by marking one of the five categories, “few days”, “one week“, ‘&onemonth”, “1-3 months”, “more than three months”. Finally, she was asked to indicate whether she had received treatment for depression. The diagnosis of depression was established by two means, as follows: (A) Those patients whose experience of misery and depression was greater than half the time, and who also felt a burden more than half the time, and in whom these changes persisted more than a month, were judged to be depressed on the basis of symptomatology. (B) Those patients who received treatment for post-partum depression were also judged to have been depressed. This criterion has been used by others [e.g.6]. Of the 129 questionnaires, 50 were returned unopened, because the patients had changed address. Thirty others were not returned, although two more letters followed the initial one. Forty-nine replies were received. One patient was in social class II, five in class III, 14 in class IV, and 29 in class V. Eighteen of them were seen for the first time in first trimester, 25 in the second, and six in the third. RESULTS Depression
Five depressives were isolated using criterion A, and five using criterion B. Two patients appeared in both groups making a range of incidence from 10 to 16%. It seemed possible that criterion B was less accurate than criterion A, since one case complained only of persistent crying, a second of mood change alone, and a third, although showing the characteristic depressive profile, did not admit to profound changes. In A group, the scores on the four scales for misery, crying, hopelessness, and for feeling a burden were 8.1, 8.1, 7.1 and 7.9 respectively. In B group, the scores were 6.3, 6.5, 5.1 and 5.2. In addition to the above two groups, there were six women who felt miserable and depressed most of the time, for a month or more, but who did not show other features of clinical depression. The mean visual analogue scores were 7.9, 4.9, 2.1 and 1.9 respectively. These women were clearly distinguished from group A in terms of hopelessness and feeling a burden. The differences were statistically significant. (In the former case, mean 7.08 s.d. 2.30 c.f. mean 2.12 s.d. 1.05; t = 4.76, and p < 0.005; in the latter case, mean 7.94 s.d., 1.05 c.f. 1.93 s.d. 0.92, t = 10.12, p < 0,001). A further 20 women seemed to have experienced “maternity blues” [19]. Thirteen of them identified a mood change in the first post-partum week, while for the remaining seven, the mood change lasted somewhat longer. For this group as a whole, crying was remembered as a more frequent occurrence than depression. This difference did not reach statistical significance. (Mean score of the “misery” scale was 2.46 s.d. 1.59 c.f. mean for “crying” 3.21 s.d. 243, t = 1.96, p z 0.05). Finally, 15 women (30%) had not been depressed post-partum. Anxiety and depression
Nine women had high levels of anxiety during pregnancy using a cut-off point of 30 or above on Taylor’s Manifest Anxiety Scale. Thirty was considered appropriate, being one standard deviation from the mean of a larger sample of pregnant subjects (mean 20.94 s.d. 9.13 IZ= 204) [4]. It was also close to the mean (30.3) of 10 patients with anxiety states 1121. Of these nine women, five developed post-partum depression. The relationship is significant (p -X 0.02) using the four-fold table. Ten women had high levels of neuroticism during pregnancy, using a cut-off 18 or above on the Eysenck Personality Inventory. Eighteen is one standard deviation above the mean of a pregnant population (mean 12.50 s.d. 4.91, n = 205) [4]. The mean scores for a group with anxiety states was 18.6 1121. Of these ten women, six developed post-partum depression. The relationship is significant (p -C 0%X2) using the four-fold table. The alternative relation also held. Those eight women deemed to have suffered post-partum depres-
A possible relationship between anxiety in pregnancy and puerperal depression
601
sion had a mean anxiety score of 31.0 s.d. 5.45 during pregnancy which was significantly higher than the mean score of the remainder, 17.90 s.d. 8.78 (t = 4.05, p 4 OGOl). The scores for neuroticism showed a similar difference. The mean score for the depressives was 18.62 s.d. 256 compared with il.15 s.d. 4.99 (t = 4.11, p < 0~001). If those six who had a persisting mood change but who were not considered to be clinically depressed were added to the depressives, the mean anxiety score, 26.36 s.d. 8.47 remained significantly higher than the remainder 17.51 s.d. 8.89 (t = 3.17, p < 0.005). The scores for neuroticism also remained significantly higher-15.86 s.d. 4.11 compared with 10.94 s.d. 5.31 (t = 3.12, p < 0.005). Those who experienced transient “maternity blues” had a mean anxiety score, 18.80 s.d. 10.23 which was not significantly higher than those who did not admit to experiencing depression, 15.80 s.d. 6.86 (t = 0.98). The neuroticism scores were also insignificantly different-12.05 s.d. 5.53 compared with 9.53 s.d. 4.79 (t = 1.41). The mean anxiety and neuroticism scores for the various categories of post-partum mood change are shown in the table. Other details of the depressives
Further details of the eight women who showed evidence of post-partum depression are as follows: (i) Time of first visit-two were seen in the first trimester, four in the second, and two in the third. (ii) Parity-two were nulliparous, two had one child, and four were multiparous. This compared with 14,11 and 16 of the respective categories for the non-depressed. (iii) Breast feeding-seven breast fed compared with 26 of the 41 other women. (iv) Sexuality-one depressive, compared with six of the remainder, did not find much enjoyment in her sexual life. (v) Length of labour-the mean length of the first stage for the depressives was 12.8 hr compared with 12.2 for the others. (vi) Abnormal delivery-there were no abnormal deliveries (caesarean, forceps) amongst the depressives and 11 among the remainder. None of these differences reaches statistical significance.
DISCUSSION Four kinds of puerperal mood change could be distinguished using the visual analogue scales. First, there was a small group who showed the symptoms of a depressive disorder. Secondly, there was a group who showed an equally profound mood change, which persisted for more than a month post-partum but which was not accompanied by the other symptoms of depressive illness. Thirdly, a large number of women showed a brief period of episodic mood change which was characterized more by crying than by depression. Finally, about a third of the women showed no mood change. Five women who had received treatment for puerperal depression had a form of depression which had characteristics, on the visual analogue scales, which fell between the first two groups. The groups distinguished in this way, formed a hierarchy of severity of mood change during the puerperium which corresponded with a somewhat similar hierarchy of mean scores for anxiety and for neuroticism during pregnancy. Furthermore, those women regarded as clinically depressed during the post-partum period, that is, those who showed the appropriate profile of depressive symptoms, together with those who had received treatment for depression, showed mean anxiety scores and neuroticism scores during pregnancy which were significantly higher from those of the remainder. These findings are in accord with Tod’s conclusion that peurperal depression is heralded by anxiety in pregnancy [Sj. The reverse relationship also held, so that the highest levels of anxiety in pregnancy tended to predict puerperal depression. It seems that this is the first psychometric confirmation of Tod’s original report, although Dalton [6] produced clinical findings which were partly consistent with his. She had a number of doctors assess women at least seven times during their pregnncy. Each assessment included a clinical estimate of anxiety. Only on the first occasion, it seems, did those who subsequently develop puerperal depression
608
RUSSELL MEARES, JAMESGRIMWADEand CARL WOOD
show a significantly greater proportion of apparently anxious women than the remainder. She inferred that although Tod was correct in his conclusion, it was only when anxiety appeared early in pregnancy that it predicted puerperal depression. In the present study, however, the assessment of anxiety, for the majority of depressives, was carried out in the second or third trimesters. A more likely explanation of Dalton’s failure to find anxiety throughout pregnancy is that a simple clinical estimate, presumably of a binary nature, is insufficiently sensitive. Secondly, its reliability is dubious. The failure of Pitt [20] to discover a relationship between anxiety in pregnancy and puerperal depression may also be explained on methodological grounds. He used a questionnaire which was validated against the Hamilton Rating Scale for depression and which included only one question relating to anxiety. Nevertheless, he inferred that since puerperal depressives did not score significantly higher on this scale during pregnancy than did controls, anxiety in pregnancy did not predict puerperal depression. A more obvious inference from his study might be that depression itself, when experienced in pregnancy, is not predictive of post-partum depression. This is consistent with Dalton’s findings [6]. The present study does not test the hypothesis that depression in pregnancy predicts post-partum depression, but the above studies, particularly Pitt’s do not favour the hypothesis.
The group of women in this study were atypical in that social classes IV and V were over-represented. Moreover, although the follow-up a similar proportion of cases to that of Dalton’s, the drop out was considerable. Nevertheless, it seems unlikely that the anxiety in pregnancy shown by those who suffered puerperal depression could be explained in terms of sampling, since the finding depends upon an intra-group correlation rather than a comparison between groups. Furthermore, the incidence of the various forms of mood change following child-birth in this study does not suggest that the present sample differs strikingly from that of other studies. The incidence of post-partum depression, as defined by profile of symptoms, was 10%. Pitt [20] also found a 10 ‘A incidence. Dalton [6] found an incidence of 7 %. The need for treatment was her criterion for depression. When this method of isolation of puerperal depressives was used together with the visual analogue scales, our incidence rose to 16%. When the group of women who showed a profound and persisting mood change post-partum, but who are not considered to be clinically depressed, were added to the depressed group, 28 % of this sample showed a significant mood disturbance. This compares with a figure of 34 % given by Dalton for women who showed some form of depression post-partum, most of them not requiring treatment [6]. When the transient experience of depression, commonly called the “blues”, is added to the more severe forms of mood change, the incidence of post-partum mood change rises to 70 %. This is in accord with the 80 % figure given by Robin [21] and also with a 65 % figure given by Pitt [20] quoting an unpublished study. Pitt himself, however, [19] gave an incidence of 50% for “maternity blues”.
It is sometimes contended that puerperal depression occurs in women who are ambivalent about their female roles and, in particular, the maternal role [e.g. 221. If breast feeding can be said to reflect acceptance of the maternal role, then this study provides no evidence in favour of the contention. In fact, it is consistent with the findings of Dalton who showed that the puerperal depressives were more likely to have positive attitudes towards lactation than other pregnant women. Rejection of femininity together with sexual difficulties is also said to be associated with puerperal depression [e.g. 231, but again no evidence was found to favour this notion. Profession of enjoyment of their sexual life might, on the face of it, be considered to reflect a lack of sexual difficulty. There was no difference between the depressives and the remainder in terms of lack of enjoyment of their sexual lives. It must be admitted, however, that gross behavioural observations give crude reflections of complicated states of identity. Nevertheless, if it were supposed that some women were peculiarly vulnerable to the stress of pregnancy and parturition due to their psychodynamic structure, then those having high anxiety scores in pregnancy, these being largely predictive of post-partum depression, should form a group distinct from the remainder of pregnant women. In this case, one would expect
A possible relationship between anxiety in pregnancy and puerperal depression
609
a bimodal distribution of anxiety scores during pregnancy. Some evidence, however, suggests that the distribution is unimodal [4]. Finally, puerperal depression could not be explained, in this study, in terms of the difficult circumstances of the delivery. There was little difference in mean length of the first stage for the depressives when compared with others, and none of them had abnormal deliveries compared with 11 abnormal deliveries in the remainder. Fleeting despondency, together with minor cognitive changes are so common in the early puerperium [24, 251 that a hormonal basis seems likely [19]. The various findings of this study, when taken together, are consistent with the possibility that biological, presumably endocrine, factors may also be important in the production of the more severe forms of post-partum depression. Furthermore, the findings suggest that anxiety which may be a general characteristic of pregnancy may also have a hormonal basis since it seems to be linked with post-partum depression. Other studies, however, suggest that it may not be the only affective state linked with post-partum depression. Dalton [6], for example, found that elation, but not depression, in pregnancy is associated with puerperal depression. States of depression and of anxiety can be distinguished, not only clinically, but also on physiological grounds. Nevertheless, there seems to be a link between them, which is often conceptualized in psychodynamic terms. This study suggests that the differing physiological conditions of pregnancy and the puerperium may induce anxiety and depression successively in the same individual. This association might have some implications for research into the biological basis of non-psychotic mental illness. TABLE1 Post-partum state Depression A Depression B Prolonged mood change Transient “Blues” Undepressed Total
It
Anxiety in pregnancy
Neuroticism in pregnancy
5 5
33.60 s.d. 4.83 28.0 s.d. 4.18
20.0 s.d. 203 17.4 s.d. 1.82
20.17 s.d. 8.04 18.80 s.d. 10.23 1580 s.d. 6.86
12.17 s.d. 248 12.05 s.d. 5.53 9.53 s.d. 4.79
20.04 s.d. 9.62
12.37 s.d. 5.43
6 20 15 *49
*Two patients appear in both A and B.
REFERENCES 1. PUGH T. F., JERATHB. K., SCHMIDTW. M. and REED R. B. Rates of mental disease related to child-bearing. New Eng. J. Med. 268, 1224 (1963). 2. ROSENBERG A. 3. and SILVERE. Suicide, psychiatrists and therapeutic abortion. Culif. Med. 102, 407 (1965). 3. DAVIDSA., DE VAULT S. and TALMADGEA. Psychological study of emotional factors in pregnancy. A preliminary report. Psychosom. Med. 23, 93 (1961). 4. MEAREXR. A., GRIMWADEJ., BICKLEY,M. and WOOD, C. Pregnancy and neuroticism. Med. J. Amt. 1, 517 (1972). 5. TOD E. D. M. Puerperal depression: A prospective epidemiological study. Luncef 2, 1264 (1964). 6. DALTONK. Prospective study into puerperal depression. &it. J. Psychiut. 118, 689 (1971). 7. KRUPINSKIJ. and STOLLERA. The Health ofa Metropolis. Halstead, Sydney (1971).
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a. TAYLOR J. A.
Personality scale of manifest anxiety. J. Abnorm. Sot. Psychol. 48, 285 (1953). Research Approach, p. 351-6. Prentice-Hall of 9. BYRNE D. An Zntroduction to Personality-A Canada, Toronto (1966). 10. EYSENCKH. J. and EYSENCKS. B. G. Manual of the Eysenck Personality Inventory. University of London Press, London (1964). 11. LADER M. and MARKS I. Clinical Anxiety. Heinemann, London (1971). 12. HORVATH T. B. Unoublished thesis submitted for Ph.D.. University of Melbourne (1973). 13. COPPEN A. and M~TCALFE M. Effect of a depressive illness on M.P.I. scores. &.‘J. Psychiat. 111,236 (I 965). 14. KNOWLES J. and KREITMAN N. The Eysenck Personality Inventory: Some considerations. Br. J. Psychiat. 111, 755 (1965). 15. MCCALLUM P. and MEARFS R. A controlled trial of maprotiline (ludiomil) in depressed outpatients. Med. J. Aust. 2, 392 (1975). 16. SPIELBERGER C. D. and GORSUCH R. L. The development of the state-trait anxiety inventory. In Mediating Process in Verbal Conditioning (Edited by SPEILBERGER C. D. and GORSUCHR. L.). Government Printing Office, Washington, D.C. (1966). 17. AITKEN R. C. B. A measure of feelings using visual analogue scales. Proc. Roy. Sot. Med. 62,
989 (1969). 18. DAVIESB., BURROWSG. and POYNTONC. A comparative study of four depression rating scales. Aust. N.Z. J. Psychiat. 9, 21 (1975). 19. PITT B. “Maternity Blues”. Br. J. Psychiat. 122, 431 (1968). 20. PITT B. Atypical depression following childbirth. Br. J. Psychiat. 114, 1325 (1968). 21. ROBIN A. M. Psychological changes of normal parturition: Psychiat. Quart. 36, 129 (1962). 22. GARNER H. H. Post-partum emotional disturbances. Psychosomatics V, 275 (1964). 23. DOUGLASG. Some emotional disorders of the puerperium. J. Psychosom. Res. 12, 101 (1968). 24. TREADWAY C. R., KANE F. J. Jr., JARRAH-ZADEIIA. and LIPTONM. A. A psychoendocrine study of pregnancy and the puerperium. Am. J. Psychiat. 125, 1380 (1969). 25. KANE F. J. JR., HARMAN W. J. JR., KEELERM. H. and EWING J. A. Emotional and cognitive
disturbance
in the early puerperium.
Br. J. Psychiat. 114, 99 (1968).
A POSSIBLE RELATIONSHIP BETWEEN ANXIETY IN PREGNANCY AND PUERPERAL DEPRESSION RUSSELL
MEARES*,
JAMES GRIMWADE?
and
CARL
WOOD
1
(Received 8 December 1975) MUCH
evidence indicates that depression is common during the post-partum period [l] but is unusual in pregnancy, when suicide rates fall [2]. On the other hand, scales which correlate with subjective anxiety suggest that anxiety may be high during pregnancy, but return to normal levels during the post-partum period [3, 41. A possible relationship between anxiety in pregnancy and depression in the puerperium is suggested by the work of Tod [S]. He studied 700 consecutive pregnancies and remarked that “mild anxiety was encountered in very many pregnancies” and that “similarly, a mild form of depression was common three or four days after delivery” . . . “These minor disturbances were accepted as normal accompaniments of pregnancy and parturition”. In addition, he found 20 cases of puerperal depression, which was heralded in each case by pathological anxiety during pregnancy. Other studies indicate that depression itself, when experienced in pregnancy, is not predictive of post-partum depression [e.g. 61. In Tad’s study, however, the determination of anxiety was of dubious reliability. Tod stated that some of the pregnant women destined for puerperal depression “appeared in the best of physical and mental health, and only exhaustive probing revealed their underlying distress”. We have used objective measures in order to test the possibility that the highest levels of anxiety in pregnancy may predict the most profound forms of depression during the puerperium. METHOD The patients came from a sample of 129 married women attending an antenatal clinic at the Queen Victoria Hospital. Patients are randomly allocated to various clinics on application to the hospital, and the patients selected to enter the investigation were those who arrived for their first antenatal visit at a standard time on a particular day in consecutive weeks. Those patients whose native language was not English were excluded. No patient was rejected on other grounds and none refused to co-operate. A number of clinical details, which included a brief consideration of the patient’s sexual life, were taken. Social class was estimated by standard means, using the husband’s occupation [7]. All patients filled out the Taylor Manifest Anxiety Scale [8], which is regarded as a valid and reliable measure of anxiety [9]. A score for neuroticism was also obtained using the Eysenck Personality Inventory [lo], a widely used and well validated instrument. Neuroticism is generally conceived as having its basis in anxiety, and there is a high correlation between the two scales [Ill. In a series of 20 normal subjects, and in another of 10 patients with an anxiety state, the correlations between the two measures were 0.81 and 0.89 respectively [12]. The neuroticism scale is theoretically considered to reflect an enduring persona!ity constant which may have a biological basis. The same suggestion has also been applied to the Taylor Manifest Anxiety Scale [ll]. Certain evidence suggests, however, that the scores change significantly with changing states of depression and anxiety [e.g. 13, 141. We have therefore supposed that both scales reflect enduring personality traits and also mutable emotional states. The scales have been chosen since a previous study [15] using a questionnaire ostensibly measuring both states and traits of anxiety [16] proved unsatisfactory. Details of each woman’s labour, delivery, and whether she breast fed, were taken from the clinical notes. In order to gain adequate co-operation from the patients, it was necessary to devise a method of estimating post-partum depression which was neither tiresome nor time-consuming. The post-partum period was considered to last six months, so that six to 18 months following the birth of their child, the patients were posted a questionnaire which was largely composed of visual analogue scales for scoring depression [17]. These have been found to correlate with other standard methods of rating *Reader in Psychiatry, University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia. tFirst Assistant (Part Time), Department of Obstetrics & Gynaecology, University of Melbourne. $Professor and Chairman, Department of Obstetrics & Gynaecology, Monash University, Clayton, Victoria, Australia. 605
606
RUSSELLMEARES,JAMESGRIMWADEand CARL WOOD
depression such as the Zung and Hamilton Scales [18]. Nevertheless, the previously used visual analogue scales indicate mood change alone. The exhibition of misery or sadness is not generally considered sufficient for the clinical diagnosis of depression, which requires, in addition, evidence of hopelessness, guilt, and self-depreciation. Thus, the single measure of mood change is likely to correlate with depression but will not isolate it. We therefore used four scales. Four statements were placed above 4 lines, each 12 cm long, and on which were written, “Not at all” at one end, and “Nearly al! the time” at the other. The statements were: “I felt miserable and depressed”, “I had spells of crying”, “I felt without hope “, “I felt useless and a burden to others”. The last statement was taken to reflect minor guilt and loss of self-esteem. The patient was asked to make a cross on each line, so as to indicate how she felt following the birth of her baby. Following this, she was asked, if she had been depressed, to indicate the length of her depression by marking one of the five categories, “few days”, “one week“, ‘&onemonth”, “1-3 months”, “more than three months”. Finally, she was asked to indicate whether she had received treatment for depression. The diagnosis of depression was established by two means, as follows: (A) Those patients whose experience of misery and depression was greater than half the time, and who also felt a burden more than half the time, and in whom these changes persisted more than a month, were judged to be depressed on the basis of symptomatology. (B) Those patients who received treatment for post-partum depression were also judged to have been depressed. This criterion has been used by others [e.g.6]. Of the 129 questionnaires, 50 were returned unopened, because the patients had changed address. Thirty others were not returned, although two more letters followed the initial one. Forty-nine replies were received. One patient was in social class II, five in class III, 14 in class IV, and 29 in class V. Eighteen of them were seen for the first time in first trimester, 25 in the second, and six in the third. RESULTS Depression
Five depressives were isolated using criterion A, and five using criterion B. Two patients appeared in both groups making a range of incidence from 10 to 16%. It seemed possible that criterion B was less accurate than criterion A, since one case complained only of persistent crying, a second of mood change alone, and a third, although showing the characteristic depressive profile, did not admit to profound changes. In A group, the scores on the four scales for misery, crying, hopelessness, and for feeling a burden were 8.1, 8.1, 7.1 and 7.9 respectively. In B group, the scores were 6.3, 6.5, 5.1 and 5.2. In addition to the above two groups, there were six women who felt miserable and depressed most of the time, for a month or more, but who did not show other features of clinical depression. The mean visual analogue scores were 7.9, 4.9, 2.1 and 1.9 respectively. These women were clearly distinguished from group A in terms of hopelessness and feeling a burden. The differences were statistically significant. (In the former case, mean 7.08 s.d. 2.30 c.f. mean 2.12 s.d. 1.05; t = 4.76, and p < 0.005; in the latter case, mean 7.94 s.d., 1.05 c.f. 1.93 s.d. 0.92, t = 10.12, p < 0,001). A further 20 women seemed to have experienced “maternity blues” [19]. Thirteen of them identified a mood change in the first post-partum week, while for the remaining seven, the mood change lasted somewhat longer. For this group as a whole, crying was remembered as a more frequent occurrence than depression. This difference did not reach statistical significance. (Mean score of the “misery” scale was 2.46 s.d. 1.59 c.f. mean for “crying” 3.21 s.d. 243, t = 1.96, p z 0.05). Finally, 15 women (30%) had not been depressed post-partum. Anxiety and depression
Nine women had high levels of anxiety during pregnancy using a cut-off point of 30 or above on Taylor’s Manifest Anxiety Scale. Thirty was considered appropriate, being one standard deviation from the mean of a larger sample of pregnant subjects (mean 20.94 s.d. 9.13 IZ= 204) [4]. It was also close to the mean (30.3) of 10 patients with anxiety states 1121. Of these nine women, five developed post-partum depression. The relationship is significant (p -X 0.02) using the four-fold table. Ten women had high levels of neuroticism during pregnancy, using a cut-off 18 or above on the Eysenck Personality Inventory. Eighteen is one standard deviation above the mean of a pregnant population (mean 12.50 s.d. 4.91, n = 205) [4]. The mean scores for a group with anxiety states was 18.6 1121. Of these ten women, six developed post-partum depression. The relationship is significant (p -C 0%X2) using the four-fold table. The alternative relation also held. Those eight women deemed to have suffered post-partum depres-
A possible relationship between anxiety in pregnancy and puerperal depression
601
sion had a mean anxiety score of 31.0 s.d. 5.45 during pregnancy which was significantly higher than the mean score of the remainder, 17.90 s.d. 8.78 (t = 4.05, p 4 OGOl). The scores for neuroticism showed a similar difference. The mean score for the depressives was 18.62 s.d. 256 compared with il.15 s.d. 4.99 (t = 4.11, p < 0~001). If those six who had a persisting mood change but who were not considered to be clinically depressed were added to the depressives, the mean anxiety score, 26.36 s.d. 8.47 remained significantly higher than the remainder 17.51 s.d. 8.89 (t = 3.17, p < 0.005). The scores for neuroticism also remained significantly higher-15.86 s.d. 4.11 compared with 10.94 s.d. 5.31 (t = 3.12, p < 0.005). Those who experienced transient “maternity blues” had a mean anxiety score, 18.80 s.d. 10.23 which was not significantly higher than those who did not admit to experiencing depression, 15.80 s.d. 6.86 (t = 0.98). The neuroticism scores were also insignificantly different-12.05 s.d. 5.53 compared with 9.53 s.d. 4.79 (t = 1.41). The mean anxiety and neuroticism scores for the various categories of post-partum mood change are shown in the table. Other details of the depressives
Further details of the eight women who showed evidence of post-partum depression are as follows: (i) Time of first visit-two were seen in the first trimester, four in the second, and two in the third. (ii) Parity-two were nulliparous, two had one child, and four were multiparous. This compared with 14,11 and 16 of the respective categories for the non-depressed. (iii) Breast feeding-seven breast fed compared with 26 of the 41 other women. (iv) Sexuality-one depressive, compared with six of the remainder, did not find much enjoyment in her sexual life. (v) Length of labour-the mean length of the first stage for the depressives was 12.8 hr compared with 12.2 for the others. (vi) Abnormal delivery-there were no abnormal deliveries (caesarean, forceps) amongst the depressives and 11 among the remainder. None of these differences reaches statistical significance.
DISCUSSION Four kinds of puerperal mood change could be distinguished using the visual analogue scales. First, there was a small group who showed the symptoms of a depressive disorder. Secondly, there was a group who showed an equally profound mood change, which persisted for more than a month post-partum but which was not accompanied by the other symptoms of depressive illness. Thirdly, a large number of women showed a brief period of episodic mood change which was characterized more by crying than by depression. Finally, about a third of the women showed no mood change. Five women who had received treatment for puerperal depression had a form of depression which had characteristics, on the visual analogue scales, which fell between the first two groups. The groups distinguished in this way, formed a hierarchy of severity of mood change during the puerperium which corresponded with a somewhat similar hierarchy of mean scores for anxiety and for neuroticism during pregnancy. Furthermore, those women regarded as clinically depressed during the post-partum period, that is, those who showed the appropriate profile of depressive symptoms, together with those who had received treatment for depression, showed mean anxiety scores and neuroticism scores during pregnancy which were significantly higher from those of the remainder. These findings are in accord with Tod’s conclusion that peurperal depression is heralded by anxiety in pregnancy [Sj. The reverse relationship also held, so that the highest levels of anxiety in pregnancy tended to predict puerperal depression. It seems that this is the first psychometric confirmation of Tod’s original report, although Dalton [6] produced clinical findings which were partly consistent with his. She had a number of doctors assess women at least seven times during their pregnncy. Each assessment included a clinical estimate of anxiety. Only on the first occasion, it seems, did those who subsequently develop puerperal depression
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show a significantly greater proportion of apparently anxious women than the remainder. She inferred that although Tod was correct in his conclusion, it was only when anxiety appeared early in pregnancy that it predicted puerperal depression. In the present study, however, the assessment of anxiety, for the majority of depressives, was carried out in the second or third trimesters. A more likely explanation of Dalton’s failure to find anxiety throughout pregnancy is that a simple clinical estimate, presumably of a binary nature, is insufficiently sensitive. Secondly, its reliability is dubious. The failure of Pitt [20] to discover a relationship between anxiety in pregnancy and puerperal depression may also be explained on methodological grounds. He used a questionnaire which was validated against the Hamilton Rating Scale for depression and which included only one question relating to anxiety. Nevertheless, he inferred that since puerperal depressives did not score significantly higher on this scale during pregnancy than did controls, anxiety in pregnancy did not predict puerperal depression. A more obvious inference from his study might be that depression itself, when experienced in pregnancy, is not predictive of post-partum depression. This is consistent with Dalton’s findings [6]. The present study does not test the hypothesis that depression in pregnancy predicts post-partum depression, but the above studies, particularly Pitt’s do not favour the hypothesis.
The group of women in this study were atypical in that social classes IV and V were over-represented. Moreover, although the follow-up a similar proportion of cases to that of Dalton’s, the drop out was considerable. Nevertheless, it seems unlikely that the anxiety in pregnancy shown by those who suffered puerperal depression could be explained in terms of sampling, since the finding depends upon an intra-group correlation rather than a comparison between groups. Furthermore, the incidence of the various forms of mood change following child-birth in this study does not suggest that the present sample differs strikingly from that of other studies. The incidence of post-partum depression, as defined by profile of symptoms, was 10%. Pitt [20] also found a 10 ‘A incidence. Dalton [6] found an incidence of 7 %. The need for treatment was her criterion for depression. When this method of isolation of puerperal depressives was used together with the visual analogue scales, our incidence rose to 16%. When the group of women who showed a profound and persisting mood change post-partum, but who are not considered to be clinically depressed, were added to the depressed group, 28 % of this sample showed a significant mood disturbance. This compares with a figure of 34 % given by Dalton for women who showed some form of depression post-partum, most of them not requiring treatment [6]. When the transient experience of depression, commonly called the “blues”, is added to the more severe forms of mood change, the incidence of post-partum mood change rises to 70 %. This is in accord with the 80 % figure given by Robin [21] and also with a 65 % figure given by Pitt [20] quoting an unpublished study. Pitt himself, however, [19] gave an incidence of 50% for “maternity blues”.
It is sometimes contended that puerperal depression occurs in women who are ambivalent about their female roles and, in particular, the maternal role [e.g. 221. If breast feeding can be said to reflect acceptance of the maternal role, then this study provides no evidence in favour of the contention. In fact, it is consistent with the findings of Dalton who showed that the puerperal depressives were more likely to have positive attitudes towards lactation than other pregnant women. Rejection of femininity together with sexual difficulties is also said to be associated with puerperal depression [e.g. 231, but again no evidence was found to favour this notion. Profession of enjoyment of their sexual life might, on the face of it, be considered to reflect a lack of sexual difficulty. There was no difference between the depressives and the remainder in terms of lack of enjoyment of their sexual lives. It must be admitted, however, that gross behavioural observations give crude reflections of complicated states of identity. Nevertheless, if it were supposed that some women were peculiarly vulnerable to the stress of pregnancy and parturition due to their psychodynamic structure, then those having high anxiety scores in pregnancy, these being largely predictive of post-partum depression, should form a group distinct from the remainder of pregnant women. In this case, one would expect
A possible relationship between anxiety in pregnancy and puerperal depression
609
a bimodal distribution of anxiety scores during pregnancy. Some evidence, however, suggests that the distribution is unimodal [4]. Finally, puerperal depression could not be explained, in this study, in terms of the difficult circumstances of the delivery. There was little difference in mean length of the first stage for the depressives when compared with others, and none of them had abnormal deliveries compared with 11 abnormal deliveries in the remainder. Fleeting despondency, together with minor cognitive changes are so common in the early puerperium [24, 251 that a hormonal basis seems likely [19]. The various findings of this study, when taken together, are consistent with the possibility that biological, presumably endocrine, factors may also be important in the production of the more severe forms of post-partum depression. Furthermore, the findings suggest that anxiety which may be a general characteristic of pregnancy may also have a hormonal basis since it seems to be linked with post-partum depression. Other studies, however, suggest that it may not be the only affective state linked with post-partum depression. Dalton [6], for example, found that elation, but not depression, in pregnancy is associated with puerperal depression. States of depression and of anxiety can be distinguished, not only clinically, but also on physiological grounds. Nevertheless, there seems to be a link between them, which is often conceptualized in psychodynamic terms. This study suggests that the differing physiological conditions of pregnancy and the puerperium may induce anxiety and depression successively in the same individual. This association might have some implications for research into the biological basis of non-psychotic mental illness. TABLE1 Post-partum state Depression A Depression B Prolonged mood change Transient “Blues” Undepressed Total
It
Anxiety in pregnancy
Neuroticism in pregnancy
5 5
33.60 s.d. 4.83 28.0 s.d. 4.18
20.0 s.d. 203 17.4 s.d. 1.82
20.17 s.d. 8.04 18.80 s.d. 10.23 1580 s.d. 6.86
12.17 s.d. 248 12.05 s.d. 5.53 9.53 s.d. 4.79
20.04 s.d. 9.62
12.37 s.d. 5.43
6 20 15 *49
*Two patients appear in both A and B.
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