Research Proposal: Postpartum Depression

One of the most serious mental health issues that affect the entire family unit is that of postpartum depression.  This complex mental disorder is hard to detect, diagnose, and treat but affects millions of new parents each year.  The time of bringing a baby into the world should be both exhilarating and stressful, but it should never result in the depression of one of, or both of, the parents.  It is for this reason that psychologists have spent countless hours and resources in further understanding this disorder in the hopes of being able to identify the symptoms that are displayed physically and psychologically and link them to the complex chemical reactions that occur within one’s brain.  It is through the study of the symptoms that are presented by individuals that science may one day be able to finally end this tragic, terrible mental disorder from inflicting itself against new parents when they should be experiencing some of the most joyous times of their lives and that of their new child.  

It is important to realize that the role that postpartum depression plays is not simply limited to the person that it inflicts.  As with many mental disorders, the consequences of postpartum depression take their toll on all of those that play an integral part of the sufferer’s life.  This includes both the spouse and the new child, or in the case of teenage pregnancy, with the grandparents.  The effects that this mental disorder can have on the patient’s entire family life are multiplied as the earliest stages of development for a child are some of the most critical.  It is for this reason that further scientific inquiry must be taken in order to fully understand and comprehend this disorder.  With further research and investigation, psychologists, as well as others such as clinicians, could one day hope to be able to identify early warning signs of the disorder and begin preemptive treatment that will limit the extent that the patient suffers from the effects of postpartum depression.

Speaking generally, postpartum depression is defined as a, “severe long-lasting form of depression,” (Mayo Clinic Staff) that follows childbirth, and is characterized by the onset of such symptoms within the first year of the child’s birth (Wolf, 2010).  As noted by the Mayo Clinic, it is not uncommon for a new parent to experience a large, varying wave of emotions ranging from “excitement and joy to fear and anxiety,” (Mayo Clinic Staff), however there are cases where the new parent will feel the emotion of depression.  In rarer cases still, the new parent can even experience a severe form of postpartum depression that is postpartum psychosis, which develops after childbirth (Mayo Clinic Staff).  The root cause for postpartum depression is not entirely understood as of now, but there are believed to be multiple factors that play a role in the development and onset of the symptoms of the disorder.  These factors are linked to changes in the patient’s life that are caused by the pregnancy and birth of a child and include physical, emotional, and lifestyle changes (Mayo Clinic Staff).

Of all of these changes that can play a role in the development and persistence of postpartum depression, one factor that is receiving more and more investigation is the role and relationship between the spouse and the patient.  According to a study carried out by Brian Don and Kristin Mickelson, one of the root causes and links between maternal and paternal postpartum depression is the “impaired spousal support and reduced relationship satisfaction,” (Don & Mickelson, 2012).  Their study found there to be an indirect link between the two parental forms of postpartum depression and saw the importance of the role that being supportive of and towards each other could have (Don & Mickelson, 2012).  What is of particular interest with a study such as this is that it raises the importance of the issue that the spousal relationship has on each of the parents during the immediate time frame after the child’s birth.  

One of the other factors that plays a large role in the onset and early stages of postpartum depression is that of the psychological health of the parent based on their previous life experiences.  A case study from Beydoun et al found that there was a direct link between postpartum depression and intimate partner violence (IPV).  The study showed that there was a 1.5 to 2-fold increase in the likelihood of a woman developing postpartum depression if she had experienced some form of IPV before giving birth (Beydoun et al, 2012).  This is of incredible relevance because of the importance that the mother has at the earliest stages of development for the child.  For example, the mother is known to observe a sleeping infant from a “reading distance” of around 40-50 cm, which is too far for a newborn’s vision to entirely focus on; whereas they will halve the distance when the newborn awakes and opens their eyes (Murray & Cooper, 1997).  What this does is, “try to reach their visual attention in various ways, and reward achievement of visual attention with expressive greeting response,” (Murray & Cooper, 38 1997).  What examples such as these small perception queues show is the importance and intimacy of the social bond that the child and its caregiver develop.  If the parent suffers from postpartum depression, it is more likely that he or she will not engage in these sorts of activities, which can result in the child not receiving the necessary social interaction that it needs and, in turn, develop its own mental disorders.

As it currently stands, the testing for postpartum depression (PPD) has been rather inconsistent and limited.  As of now, the most used test for the disorder comes from the Edinburgh Postnatal Depression Scale (EPDS).  This survey is a 10 question rates each potential answer from 1-3 on a level of severity, and the higher that the individual scores on the test, the more likely they are to be diagnosed with the disorder (Patel et al, 2012).  What becomes troubling about this method of diagnosis is in the relationship that they played with the healthcare providers that utilized the test.  As data has shown, “health care providers tended to be unfamiliar with screening instruments for PPD,” (Patel et al, 2012).  It is for this reason that a new study is to be proposed on detecting the factors that may be linked to the detection and treatment of the disorder.

The study will be a case study that looks at multiple new families that have recently given birth to a child and have been identified as being candidates for having postpartum depression.  The purpose of the study will be to determine the factors that have caused the parent(s) to develop the disorder with specific interest being played to the relationship and role of support that the afflicted patient receives from their spouse.  Through the collected data, the researcher will compile the factors that have been evaluated from the subjects’ data in the hopes of discovering a common link that exists between the patients and their development and onset of PPD.  Though there will be limitations to the study, which will be discussed at length in the Discussion section, the research will aid to the overall knowledge of the subject and the treatment of the disorder as it affects the lives of those that suffer from it.

Methods

The study will consist of a number of different families that have all had a newborn child within the last year.  Additionally, the families will all have one, or both parents, identified as being afflicted by postpartum depression.  The families that are collected for the study will be separated into 3 major groups: those with a maternal PPD, those with paternal PPD, and those with both parents suffering from PPD.  Further, these groups can be broken down into subgroups that are based upon the time in which their child was born based on months.  These groups could consist of 0-3 months, 4-8 months, and 9-12 months since the child was born.  The groups will not be altered from the time that they are originally assigned, meaning that even as the child ages and would be placed in a different age group, the original groups would be held the same throughout the course of the study.  This will allow for the groups to be referenced based not only on which parent experienced PPD symptoms, but also to which time frame the data is collected and relevant.

The experiment will be designed in the following way.  Those that are identified will first be administered the most used and respected surveys associated with PPD, including the EPDS and Postpartum Depression Screening Scale and the Pregnancy Risk Assessment Monitoring System, in order to determine the severity of their PPD.  From there, each member of the family will be separately, and with the safety of anonymity, administered a survey and interview about the relationship that exists between the patient and their spouse.  This will allow for the nature of the relationship that exists between the parents to be examined and weighed in as a factor for the severity of the PPD.  Next, the couple will undergo a CT scan and a series of other medical tests to determine the state of their brain’s chemical composition, with the specific notion of looking for chemical unbalances that are seen commonly within other forms of depression and mental illness.  Finally, the three stages of testing will be reevaluated 3 times per year on a 3-year basis, which is of some of the most important developmental stages of child development.  

The importance of the testing to the child is what will make the study different from many of the others similar to it.  Once the child reaches the age of 2 years old and older, a series of tests can be run to see how the child is developing, in a social sense, to determine what sort of effect the parent’s PPD has on the child.  What will be of the upmost importance in these tests will be the safety and long-term health of the child and, therefore, the tests that will be run on the child will only occur once so as not to cause any sort of long-term developmental issues.  The child will only be subjected to a single CT scan to see the activity of their brain and cross reference it with that of the average, healthy child to look for obvious signs of difference or other unique results that may be linked to the upbringing challenges that children of parent’s that have PPD could face.  

What would be measured, broadly, in the study would be the common factors that those that have PPD share in their symptoms and lifestyle factors that may have been a common cause for the development and manifestation of the disorder.  The study can broadly look at the effectiveness of the current means by which one is diagnosed with PPD and attempt to show that one, or more of the current tests are not the best means for diagnosing this disorder similar to the study carried out by O’Hara et el in which the effectiveness of certain questions that are asked in order to accurately attempt to diagnose some forms of PPD (O’Hara et al, 2012).  Like their study, the ultimate hopes would be to identify the limits of the current system and make suggestions for the improvement of the current model used by the scientific community.

Expected Results

The study would hopefully show the common cause between the studied couples, the development of their PPD and the resulting development that their children have at the end of the data collection.  As with many previous studies, one would expect to find that “women experiencing postpartum depression reported more stressful life events and less support from their spouses after delivery than the women not experiencing postpartum depression,” (O’Hara 1986).  In addition to this, the study would hope to find a common link between the subjects that experienced differing levels of PPD, such as the cultural differences of Latino women.  Should the resulting data find the necessary link between the groups, new, innovative forms of treatment can be offered to individuals that are suffering from PPD such as with the group therapy session that were introduced to a group of PPD suffering women from Meager and Milgrom’s 1996 pilot study.  In their study they found cognitive-behavioral group programs and CBT treatment to improve the depression symptoms that patients were experiencing dramatically (Meager & Milgrom, 1996).  The results from the proposed study could lead to therapy sessions, drug treatments, and, hopefully, general knowledge on the subject, to an extent where other successful treatment plans can be created and utilized to groups that identify with a particular group within the study.

Discussion

The overall objective of the study would be in 2 major areas.  First, the study would be a means to add to the literature and research on the subject in general.  This would allow for further research to take the results and data collected from this ambitious study and use it to further aid those afflicted by PPD.  Second, the study would be a means for which a new treatment plan could be introduced for those that already suffer from PPD.  The findings could lead to new treatment options such as new prescription medications or group therapy sessions that could aid in the continued treatment of PPD.  For example, the possibility of prescribing medications like Lithium to expectant mothers who are prone to depression. More ambitious still would be a discovery from the data collected to show the existence of a common link that may be a root cause of PPD in the first place.  This link could be seen in the personal relationships of the individuals coupled with the chemical composition of their brains and resulting brain imagery that was collected throughout the duration of the study.

Based on the knowledge from the current literature on the subject matter, it is hypothesized that the link between the stress events that face the current individual and that of their past will have a direct correlation between the severity and onset of their PPD symptoms.   Further, it is hypothesized that the individuals that report the greatest unstable relationships with their spouses will have the most severity of the onset of symptoms of PPD.  What these factors coupled with the brain imagery taken, it would be expected to find that individuals with the greatest chemical imbalances within their brains will also be the most likely to suffer from PPD.  

As noted from previous experimental data, it is common for mothers that suffer from depression to rate their children’s behavior as more volatile than that of non-depressed individuals.  According to the data collected from Forman et al, even after the treatment of their depression, mothers found that their children were, “higher in attachment security, higher in behavior problems, and more negative in temperament than nondepressed mothers,” (Forman et al, 2007).  This is relevant to the treatment of PPD because the study may find a way to more effectively treat PPD to a point where these sorts of behavior problems are no longer seen.  

One of the possible outcomes of this study would be to be able to create unique group therapy scenarios in which an identified patient can associate themselves with to combat their PPD symptoms.  As seen in multiple studies, in most cases, the use of therapy has a positive effect upon the depression symptoms.  In a study performed by Misri et al, patients in a group that received group therapy for their PPD symptoms found much more beneficial results compared to that of the control group that did not receive any therapy (Misri et al, 2000).  The results, though no unexpected, furthered the point of the benefits that therapy has had on individuals suffering from PPD, but that the extent of the therapy will be based on how helpful it is to the individual based on their needs.  This adds to the weight of the importance of the study, which could result in the creation of unique therapy groups for those that suffer from specific symptoms and onset natures of PPD.   The study also furthers one important notion of partner support, which is of critical to the study.

Some of the unexpected and most important factors that are relevant to the study can be revealed by the examination of the relationship and role of support that the spouse provides to the patient.  As noted by multiple studies and experiments, the support of the individual will depend greatly on the severity of the depression that patient will experience.  It is of the upmost importance that the spouse provides a nurturing role to the individual in order to provide them with the support that they will need to get through the disorder and not be negatively affected by it for the long-term (O’Hara et al, 1983).  However, the reporting of the nature of the relationship that the spouse has with the patient can be problematic and is one of the potential limitations to the experiment.   

The results of the study will be entirely based on the answers that patients give at the onset of the testing phase and are therefore subjected to some limitations.  First and foremost, the subjectivity of the subjects will determine the way in which the data is synthesized and analyzed.  If the subject falsely identifies a certain aspect of their relationship or past life events, the data could be incorrectly interpreted and applied.  There is also a general limitation that arises from the tests used in determining the level of PPD in the subjects.  As noted from the comprehensive view of the treatment of PPD by C.L. Dennis, the relative effectiveness of many treatments of diagnostic tools is inconclusive as their lack well-designed investigations (Dennis, 2004).  As this experiment will be based upon these tests that are not entirely conclusive, the resulting data may be subject to the same level of scrutiny.  This, of course, is based on the current limitations that face human science, technology, and general knowledge in this particular field, however.  

In general, the purpose of this study would be to add to the level of comprehension on the subject of PPD, especially when related to the role that the spouse plays on the patient’s symptom manifestation and development.  The facts of the matter are clear: PPD is a continuing threat and must be dealt with in order to provide an environment where children can be raised without suffering negative health consequences from a disorder that is not usually identified until it has manifested itself in their parent or parents.  The percentage of new mothers that receive information about PPD and its effects have only grown in recent years, showing that more and more doctors take the threat seriously.  The proposed study would serve as a link to the many different areas of research on the subject with the specific goal of linking them and finding new, unseen connections between factors that lead to the development of PPD.  Ultimately, the study aims to provide common links that exist between different patients that have PPD in the hopes of creating a new treatment option that will have positive benefits on those that share common links to their PPD.

References

Beydoun, H., Beydoun, M., Kaufman, J., Lo, B., & Zonderman, A. (2012). Intimate partner violence against adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: a systematic review and meta-analysis. Social Science & Medicine, 75(6), Retrieved from http://web.ebscohost.com.ezproxy.lib.uh.edu/ehost/detail?sid=09b13169-d726-4e06-aa2e-13eb7c0cadbc@sessionmgr14&vid=1&hid=23&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==

Dennis, C. (2004). Treatment of postpartum depression, part 2: a critical review of nonbiological interventions. Journal of Clinical Psychiatry, 65(9), Retrieved from http://europepmc.org/abstract/MED/15367054/reload=0;jsessionid=b8qkSZE4WPyMuXrJPgH8.4

Don, B., & Mickelson, K. (2012). Paternal postpartum depression: the role of maternal postpartum depression, spousal support, and relationship satisfaction. Couple and Family Psychology: Research and Practice, 1(4), Retrieved from http://web.ebscohost.com.ezproxy.lib.uh.edu/ehost/detail?sid=75fbfdbd-cf49-43ec-bbc4-b753ce70340f@sessionmgr14&vid=1&hid=23&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==

Forman, D., O'Hara, M., Stuart, S., Gorma, L., Larsen, K., & Coy, K. (2007). Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship . Development and Psychopathology, (2), Retrieved from http://journals.cambridge.org/action/displayAbstract;jsessionid=B3478C7B13F761230EDB0F4D47EB48AC.journals?fromPage=online&aid=1003112

Mayo Clinic staff. (n.d.). Postpartum depression: Causes. The Mayo Clinic, Retrieved from http://www.mayoclinic.com/health/postpartum-depression/DS00546/DSECTION=causes

Meager, I., & Milgrom, J. (1996). Group treatment for postpartum depression: a pilot study. Australian and New Zealand Journal of Psychiatry, 30(6), Retrieved from http://informahealthcare.com/doi/abs/10.3109/00048679609065055

Misri, S., Kostaras, X., Fox, D., & Kostarnas, D. (2000). The impact of partner support in the treatment of postpartum depression. The Canadian Journal of Psychiatry, 45(6), Retrieved from http://psycnet.apa.org/index.cfm?fa=search.displayRecord&UID=2000-02530-006

Murray, L., & Cooper, P. (1997). Postpartum depression and child development. New York, NY: The Guilford Press.

O'Hara, M. (1983). Postpartum depression: a role for social network and life stress variables. Journal of Nervous & Mental Disease, 171(6), Retrieved from http://journals.lww.com/jonmd/Abstract/1983/06000/Postpartum_Depression__A_Role_for_Social_Network.2.aspx

O'Hara, M. (1986). Social support, life events, and depression during pregnancy and the puerperium. Arch Gen Psychiatry, 43(6), Retrieved from http://archpsyc.jamanetwork.com/article.aspx?articleid=493821

O'Hara, M., Stuart, S., Watson, D., Dietz, P., Farr, S., & D'Angelo, D. (2012). Brief scales to detect postpartum depression and anxiety symptoms. Journal of Women's Health, 21, Retrieved from http://web.ebscohost.com.ezproxy.lib.uh.edu/ehost/detail?sid=8ad700d6-33b1-41b1-9ffb-dd3d38185d25@sessionmgr10&vid=2&hid=23

Patel, M., Bailey, R., Jabeen, S., Ali, S., Barker, N., & Osiezagha, K. (2012). Postpartum depression: A review. Journal of Health Care for the Undeserved, 23(2), Retrieved from http://web.ebscohost.com.ezproxy.lib.uh.edu/ehost/detail?sid=e272ff3a-21ad-45f3-b0a9-a6088fc99b30@sessionmgr4&vid=2&hid=23

Wolf, R. (2010, Dec 18). Postpartum depression: a history. Health Guide, Retrieved from http://www.healthguideinfo.com/postpartum-depression/p99788/