Arch Womens Ment Health (2015) 18:539–546 DOI 10.1007/s00737-014-0478-8

ORIGINAL ARTICLE

Personality and risk for postpartum depressive symptoms S. I. Iliadis & P. Koulouris & M. Gingnell & S. M. Sylvén & I. Sundström-Poromaa & L. Ekselius & F. C. Papadopoulos & A. Skalkidou

Received: 14 June 2014 / Accepted: 18 October 2014 / Published online: 6 November 2014 # Springer-Verlag Wien 2014

Abstract Postpartum depression (PPD) is a common childbirth complication, affecting 10–15 % of newly delivered mothers. This study aims to assess the association between personality factors and PPD. All pregnant women during the period September 2009 to September 2010, undergoing a routine ultrasound at Uppsala University Hospital, were invited to participate in the BASIC study, a prospective study designed to investigate maternal well-being. Depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale (EPDS) while the Depression Self-Rating Scale (DSRS) was used as a diagnostic tool for major depression. Personality traits were evaluated using the Swedish Universities Scale of Personality (SSP). One thousand thirtyseven non-depressed pregnant women were included in the study. Non-depressed women reporting high levels of neuroticism in late pregnancy were at high risk of developing postpartum depressive symptoms (PPDSs) at 6 weeks and 6 months after delivery, even after adjustment for confounders (adjusted odds ratio (aOR)=3.4, 95 % confidence interval (CI) 1.8–6.5 and adjusted odds ratio (aOR)=3.9, 95 % CI 1.9–7.9). The same was true for a DSRS-based diagnosis of major depression at 6 months postpartum. Somatic trait anxiety and psychic trait anxiety were associated with increased risk for PPDS at 6 weeks (aOR=2.1, 95 % CI 1.2–3.5 and aOR= 1.9, 95 % CI 1.1–3.1), while high scores of mistrust were associated with a twofold increased risk for PPDS at 6 months postpartum (aOR 1.9, 95 % CI 1.1–3.4). Non-depressed S. I. Iliadis (*) : M. Gingnell : S. M. Sylvén : I. Sundström-Poromaa : A. Skalkidou Department of Women’s and Children’s Health, Uppsala University, Uppsala University Hospital, 751 85 Uppsala, Sweden e-mail: [email protected] P. Koulouris : L. Ekselius : F. C. Papadopoulos Department of Neuroscience, Psychiatry, Uppsala University, Uppsala University Hospital, 751 85 Uppsala, Sweden

pregnant women with high neuroticism scores have an almost fourfold increased risk to develop depressive symptoms postpartum, and the association remains robust even after controlling for most known confounders. Clinically, this could be of importance for health care professionals working with pregnant and newly delivered women. Keywords Personality . Neuroticism . Mistrust . Trait anxiety . Postpartum depression

Introduction Postpartum depression (PPD) is defined as a major depressive episode with onset within 4 weeks after delivery (American Psychiatric Association 2000). However, this diagnostic window for PPD is considered too restrictive and it is generally extended in order to include the first 6 to 12 months postpartum (American Psychiatric Association 2013). The prevalence of PPD is consistently reported to vary around 10–15 % in most developed countries (Gaynes et al. 2005). Several major antenatal risk factors for the development of PPD have been identified, including previous history of depression, low social support, anxiety, depression, and stressful life events during pregnancy, history of premenstrual symptoms, and thyroid dysfunction (Gaynes et al. 2005; Robertson et al. 2004; Sylven et al. 2012, 2013). Despite the high prevalence of depression during the puerperium, it remains an underdiagnosed condition that can have a negative impact on the mother-infant attachment as well as the relationship between the mother and her partner (Beck 1995). Several studies have established an association between personality factors and risk for depression in non-pregnant subjects. More specifically, neuroticism appears to be strongly associated with lifetime risk for major depression in adults (Berlanga et al. 1999; Enns and Cox 1997; Gershuny and Sher

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1998; Goodwin and Gotlib 2004; McFatter 1994; Roberts and Kendler 1999; Scott et al. 1995). High neuroticism relates to feelings of tension, emotional lability, and insecurity, while low levels of neuroticism indicate emotional stability. Furthermore, low extraversion, dependency, harm avoidance, perfectionism, and self-criticism have also been associated with affective disorders (Brown et al. 1992; Enns and Cox 1997; Gelabert et al. 2012; Gershuny and Sher 1998; McFatter 1994; Smith et al. 2005). Low extraversion is associated with inhibition and shyness in social interactions, whereas sociability and feelings of competence in social interactions indicate high levels of extraversion (Verkerk et al. 2005). Previous studies have examined the association between neuroticism and postpartum depression (Boyce et al. 1991; Gelabert et al. 2011, 2012; Lee et al. 2000; Martin-Santos et al. 2012; Podolska et al. 2010; Saisto et al. 2001; van Bussel et al. 2009; Verkerk et al. 2005). However, these studies vary in terms of design, measures of personality factors, and diagnostic tools used to assess depressive symptoms during the puerperium. Most studies assess study subjects during the postpartum period when the personality evaluation can be distorted due to depressive symptoms depending on either PPD or depression with onset prior to childbirth (Gelabert et al. 2011, 2012; Lee et al. 2000; Martin-Santos et al. 2012; Podolska et al. 2010; Saisto et al. 2001; van Bussel et al. 2009). Out of those, many have not taken into consideration that personality features can be state-dependent, possibly leading to biased conclusions (Hirschfeld et al. 1983a, b). The findings of these studies point, nevertheless, to a positive association between neuroticism and risk for PPD. High introversion (or low extraversion) (Dennis et al. 2004; Gelabert et al. 2011; van Bussel et al. 2009; Verkerk et al. 2005), harm avoidance (Dennis and Boyce 2004; Gelabert et al. 2011; Josefsson et al. 2007), perfectionism (Gelabert et al. 2012) and interpersonal sensitivity (Boyce et al. 1991; Matthey et al. 2000) have also been identified as personality factors associated with increased risk of PPD. With the present study, we intended to test the hypothesis that certain personality factors and/or traits, assessed in nondepressed women in late pregnancy, influence the risk of developing postpartum depressive symptoms (PPDSs) and postpartum depression (PPD), even after adjusting for most known confounders.

Materials and methods The current study was undertaken as a part of the BASIC project, a population-based, longitudinal study of affective disorders during pregnancy and the postpartum period in Uppsala County, Sweden. The study was conducted at the Department of Obstetrics and Gynecology at Uppsala University Hospital, which is responsible for all delivering women

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within the county, as well as for high-risk pregnancies from nearby counties. Psychometric measures The Swedish universities Scale of Personality (SSP) was administered for the evaluation of personality traits (Schaling et al. 1994). The SSP is a self-rating questionnaire, based on the Karolinska Scales of Personality (KSP) (Schalling et al. 1987), which was rationally developed with the aim of assessing vulnerability for psychopathology. SSP is developed to assess personality traits and does not intend to evaluate depressive symptoms. Compared to KSP, SSP has a reduced number of items and an improved psychometric quality with better face validity, higher internal consistency, and better response differentiation (Gustavsson et al. 2000). The SSP contains 91 statements; e.g., “I’m the kind of person who is excessively sensitive and easily hurt,” and the participants rated each item on a scale from 1 to 4, where 1 equals “does not apply at all” and 4 equals “applies completely.” The items form 13 scales or traits. For each scale, the SSP scores are transformed into normative T scores with means of 50 and standard deviations of 10 based on a Swedish gender-stratified non-patient sample (Gustavsson et al. 2000). Following factor analysis, these scales are usually grouped into three major factors: neuroticism (somatic trait anxiety, psychic trait anxiety, stress susceptibility, lack of assertiveness, embitterment, mistrust), aggressiveness (trait irritability, verbal trait aggression, physical trait aggression, inversed value of social desirability), and extraversion (impulsiveness, adventure seeking, inversed value of detachment) (Gustavsson et al. 2000). Perinatal depression was assessed with two different instruments. The first one, filled out by all women in the sample, was the Edinburgh Postnatal Depression Scale (EPDS), an internationally used ten-item self report questionnaire, designed as a screening tool to identify depressive symptoms in the perinatal period. An EPDS score of 12 points or more correctly identifies 72 % of mothers experiencing a minor or major depressive episode (SBU 2012). Test specificity is estimated to be 88 % (SBU 2012). For the present study, a cutoff point of 13 points was used to define probable cases of depression during pregnancy (Rubertsson et al. 2011) and 12 points was used as cutoff point for identification of women with significant depressive symptoms postpartum (Wickberg and Hwang 1996). The second instrument used was the Depression SelfRating Scale (DSRS). The scale was designed to cover the A-criterion for a major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 2000) in a self-rating form. The form has been tested in patients with incapacitating pain syndromes, and agreement

Personality and risk for postpartum depressive symptoms

between self-rated and clinical expert-rated diagnoses was very good (kappa=0.87), and sensitivity and specificity were high (0.94 and 0.96). In the current study, women fulfilling the DSM-IV- A criterion for depression were considered as cases (Svanborg and Ekselius 2003). Study population All women within the Uppsala County planned for routine ultrasound in gestational weeks 16–18 between September 2009 and September 2010 were asked if they were willing to participate in a study of maternal well-being during and after pregnancy. Exclusion criteria for the study were (1) age less than 18, (2) inability to adequately communicate in Swedish, (3) women whose personal data were kept confidential, and (4) women with pathologic pregnancies as diagnosed by routine ultrasound. Written informed consent was obtained. The study subjects were instructed to complete a webbased self-administrated structured questionnaire containing the Swedish validated version of the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al. 1987) at pregnancy weeks 17 and 32, as well as 6 weeks and 6 months after delivery. Participating women were also administered the Swedish universities Scale of Personality (SSP) at gestational week 32, as well as the DSRS at 6 months postpartum. One hundred eight pregnant women who had an EPDS score higher than or equal to 13 at gestational week 32 (9.4 %) were excluded from further analyses in order to avoid bias due to a possible depressive state effect on personality trait measures. Statistical analyses Factor analysis for personality traits was performed with varimax rotation in order to identify factors with eigenvalues >1. Principal axis factoring was used as the extraction method, and the limit for factor loading was set at >0.45. MannWhitney U test was used as non-parametric significance test when comparing the scores of personality factors among depressed and non-depressed women. Spearman correlation coefficient (r) was used to test the non-parametric correlations between the EPDS score and the score of each of the three personality factors. Logistic regression analyses were also performed, with PPD, defined as having an EPDS score of 12 or higher, as the dependent variable. Personality traits and factors were inserted in the model as dichotomous independent variables grouped as the highest quartile versus two lowest quartiles, in order to reduce misclassification. Furthermore, backward stepwise logistic regression-derived odds ratios (ORs) were also calculated for all 13 personality traits included in the SSP scale (inserted in the model dichotomized as the highest quartile versus the rest) in relation to PPD status. Statistically significant traits were identified for further analyses. Similar

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statistical analysis was performed using the DSRS A criterion for depression as the dependent variable at 6 months postpartum. The association of known risk factors, such as history of previous depression, educational level, employment, breastfeeding, partner support, sleep, and stressful life events with the presence of PPDSs, was first assessed with univariate analyses. Factors which yielded associations with a p value ≤0.25 at either 6 weeks or 6 months were thereafter included in the multivariate logistic regression models, where ORs and 95 % confidence intervals (CI) were calculated. IBM SPSS version 20 software (SPSS Inc., Chicago, IL) was used for data analysis. Statistical significance was set at a p value of 0.45

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Table 2 presents the median scores of the three personality factors and all 13 personality traits among women with selfreported depression (defined as EPDS ≥12) and healthy controls at 6 weeks and 6 months after delivery (Mann-Whitney U test, significance level p

Personality and risk for postpartum depressive symptoms.

Postpartum depression (PPD) is a common childbirth complication, affecting 10-15 % of newly delivered mothers. This study aims to assess the associati...
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