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Attitudes toward motherhood in postnatal depression: Development of the Maternal Attitudes Questionnaire
Journal of Psychosomatic Research, Vol. 43, No. 4, pp. 351-358, 1997 Copyright © 1997 Elsevier Science Inc. All rights reserved. 0022-3999/97 $17,00 + .00
ELSEVIER
S0022.3999(97)00128-1
ATTITUDES TOWARD MOTHERHOOD IN POSTNATAL DEPRESSION: DEVELOPMENT OF THE MATERNAL ATTITUDES QUESTIONNAIRE RACHEL WARNER,* LOUIS APPLEBY,* ANNA WHITTON* and B R I A N F A R A G H E R t
(Received 23 December 1996; accepted 11 April 1997) Abslraet--This article describes the development of the Maternal Attitudes Questionnaire (MAQ), a 14-item self-report instrument measuring cognitions relating to role change, expectations of motherhood, and expectations of the self as a mother in postnatal women. This questionnaire was found to have good test-retest and internal reliability. In a large sample of women (n =483) at 6-8 weeks postpartum, scores on the questionnaire were highly correlated with scores on the Edinburgh Postnatal Depression Scale (EPDS) and the Revised Clinical Interview Schedule (CIS-R). Cluster analysis demonstrated that, among depressed women with similar symptom scores on the CIS-R, the MAQ discriminated a group with low MAQ scores and a group with high MAQ scores. This finding supports the hypothesis that women who are depressed postnatally are cognitively heterogeneous; such differences may be important in understanding the etiology and determining the treatment of postnatal depression. © 1997 Elsevier Science Inc.
Keywords: Attitudes measurement; Maternal attitudes; Postnatal depression. INTRODUCTION T e n to 15% of w o m e n experience a n o n p s y c h o t i c depressive illness following childbirth [1-3] but the etiological role of childbirth itself remains controversial. S o m e w o m e n d e v e l o p depression following childbirth but not o t h e r life events [4]; however, indicating a specific postnatal vulnerability that m a y be cognitive, social, or physiological. T h e i m p o r t a n c e of m a t e r n a l cognitions in postnatal depression is also suggested by two successful t r e a t m e n t trials using cognitive interventions [5, 6] and by two studies reporting a relationship b e t w e e n low m o o d and self-perceptions of m a t e r n a l c o m p e t e n c e [7, 8]. Nevertheless, there is little evidence on the relationship b e t w e e n postnatal depression and cognitive constructs such as self-image, role definition, and attitudes t o w a r d mothering, which are likely to be i m p o r t a n t in the transition to p a r e n t h o o d [9, 10]. T h e r e are three reasons to study m a t e r n a l cognitions in relation to postnatal de*School of Psychiatry and Behavioural Sciences, University of Manchester, Withington Hospital, Manchester, UK. tResearch Support Unit, Medical School, Manchester, UK. Address correspondence to: Louis Appleby, M.D., School of Psychiatry and Behavioural Sciences, University of Manchester, Withington Hospital, Nell Lane, Manchester M20 8LR, UK. Tel: 0161 291 4362; Fax: 0161 445 9263; E-mail: [email protected] 351
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p r e s s i o n . First, c o g n i t i o n s t y p i c a l o f p o s t n a t a l d e p r e s s i o n m a y b e m o r e useful t h a n e m o t i o n a l s y m p t o m s as a t a r g e t for p s y c h o l o g i c a l t r e a t m e n t s . S e c o n d , s u b g r o u p s of p o s t n a t a l l y d e p r e s s e d w o m e n m a y b e i d e n t i f i e d , differing in t h e c o g n i t i v e f e a t u r e s o f t h e i r illness; b y i m p l i c a t i o n , t h e y m a y also b e e t i o l o g i c a l l y d i s t i n c t - - t h o s e with p r o m i n e n t m a t e r n a l c o g n i t i o n s h a v i n g a specific p o s t n a t a l v u l n e r a b i l i t y , t h o s e witho u t such c o g n i t i o n s r e s e m b l i n g w o m e n with d e p r e s s i o n at o t h e r t i m e s a n d s h o w i n g s i m i l a r risk f a c t o r s such as social a d v e r s i t y . T h i r d , c o g n i t i v e style m a y b e a p r e d i c t o r of treatment response. We describe the development of a short questionnaire identifying the expectations o f a n d a t t i t u d e s t o w a r d m o t h e r h o o d t h a t o c c u r in r e l a t i o n to d e p r e s s i v e illness in t h e p o s t n a t a l p e r i o d . T h e q u e s t i o n n a i r e is t h e n u s e d to test t h e f o l l o w i n g h y p o t h eses: t h a t m a l a d a p t i v e c o g n i t i o n s c o n c e r n i n g m o t h e r h o o d a r e p r e s e n t in s o m e , b u t n o t all, w o m e n with p o s t n a t a l d e p r e s s i o n ; t h a t w o m e n w i t h o u t t y p i c a l m a t e r n a l cogn i t i o n s will b e c h a r a c t e r i z e d b y t h e p r o m i n e n c e o f social adversity; a n d t h a t w o m e n w i t h p r o m i n e n t m a l a d a p t i v e c o g n i t i o n s will b e m o s t r e s p o n s i v e to a c o g n i t i v e l y based treatment.
METHOD
Subjects Subjects were drawn from a large population taking part in a screening program intended to recruit women with postnatal depression to a treatment trial [6]. Women were approached in the immediate postpartum period, during visits on alternate days to two maternity units in South Manchester, and asked to agree to a home visit at 6 weeks postpartum to allow screening for depression using the Edinburgh Postnatal Depression Scale (EPDS) [11]. Exclusion criteria for screening were living outside the health district and inability to speak and read English. Over a 20-month recruitment period, 2978 women were eligible, of whom 2375 (80%) agreed to be screened. Women scoring I>10 on the EPDS, a threshold at which the sensitivity is 89% [12], were interviewed using the Revised Clinical Interview Schedule (CIS-R) [13], a structured interview assessing the severity and frequency of psychological symptoms in the week prior to interview. A score of >112 on the CIS-R indicates clinically significant morbidity. With the addition of questions relating to appetite, weight change, interest in usual activities, and duration of symptoms, the CIS-R can be used to make a clinical diagnosis of major or minor depression according to Research Diagnostic Criteria (RDC) [14]. Depressed subjects were asked to enter a trial in which they received either the antidepressant fluoxetine or placebo plus either one session or six sessions of a simple counseling derived from cognitive behavior therapy [6]. Two consecutive subsamples of women who were screened were asked to participate in the present study. The first (n=50) took part in the development and initial testing of the maternal attitudes questionnaire (MAQ). The second sample (n =483) was drawn from the main study population over a period of 4 months. During the first 3 months a systematic sample of 451 consecutive subjects was recruited, as described above; there were 16 refusals. In the fourth month this sample was supplemented with 32 subjects more likely to be depressed by collecting MAQ results only from women scoring t>10 on the EPDS.
Development of the questionnaire A review of previous literature [9, 10] and clinical experience with postnatal women suggested three areas of cognition that might be associated with depression postnatally: • expectations of motherhood; • expectations of the self as a mother; and • role conflicts. A pilot questionnaire was constructed consisting of 16 items relating to one or more of these areas. Four of the items were equivalent to items in the "attitude toward baby" subscale of the Maternal Adjustment and Maternal Attitude (MAMA) questionnaire [10], a self-administered questionnaire of 60 items relating to the marital relationship, maternal body image, attitudes toward sex, and attitudes toward the baby during pregnancy and after delivery. The new questionnaire consisted of a series of first person statements to which the subject was asked to indicate agreement or disagreement on a four-point response scale,
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similar to a Likert scale. The four-point response was used to prevent a noncommittal response set. Each item response was scored 0, 1, or 2, a higher score indicating agreement or strong agreement with "maladaptive" cognitions such as unrealistic expectations or those suggesting role conflict. A response set was avoided by wording the statements so that higher scores would sometimes indicate disagreement and sometimes agreement. A total score was obtained by adding individual item scores. The questionnaire used in the main study and the scoring of individual items are given in the Appendix. Fifty women completed the pilot questionnaire and were asked to comment on any questions that they thought were ambiguous or irrelevant. Test-retest reliability was measured at 1 week by sending the same women the questionnaire by post. This interval was expected to be long enough to prevent recall of previous responses but short enough to preclude major changes in mood and attitudes. Following the pilot study, two items were removed from the first version of the questionnaire because women reported that they were difficult to understand or answer. These items were: "I would like to have more children" and "People have to learn to be good mothers, it does not come naturally." Internal reliability and the relationship with depression were examined using the 14-item questionnaire, which was given to the main sample (n=483).
Statistical analysis The relationships between scores on EPDS or CIS-R and the maternal attitudes questionnaire were evaluated using scatterplots and correlation coefficients. Naturally occurring subgroups among the subjects with major or minor depression were sought using K-means cluster analysis; differences between identical clusters were examined using one-way analyses of variance for continuous measures and chisquare tests for categorical measures. The effect of attitudes scores on treatment response was assessed as part of an examination of several possible predictor variables using multiple linear regression methods: changes in CIS-R score at 3 months was used as the dependent variable, with total MAQ score as one of the independent variables.
RESULTS
Reliability Test-retest reliability.
Thirty-five ( 7 0 % ) o f t h e initial p i l o t s a m p l e r e t u r n e d the q u e s t i o n n a i r e o n the s e c o n d occasion. F o r i n d i v i d u a l scale items, n o significant c h a n g e s in r e s p o n s e s w e r e f o u n d b e t w e e n the t w o testing o c c a s i o n s using a W i l c o x o n p a i r e d - s a m p l e r a n k - s u m test. T h e m e a n c h a n g e in the t o t a l s c o r e was 0.0 ( 9 5 % r e f e r e n c e r a n g e _+4.6). Internal reliability. T h e v a l u e o f t h e s t a n d a r d i z e d r e l i a b i l i t y coefficient for t h e 14i t e m q u e s t i o n n a i r e was 0.84, i n d i c a t i n g a high level o f i n t e r n a l consistency.
Validity T h e i n s t r u m e n t has c o n s i d e r a b l e face validity, the initial list o f q u e s t i o n n a i r e i t e m s b e i n g d e r i v e d f r o m t w o sources: (1) clinical e x p e r i e n c e o f w o r k i n g with w o m e n suffering f r o m p o s t n a t a l d e p r e s s i o n , a n d (2) a v a i l a b l e r e s e a r c h e v i d e n c e . T h e " a t t i t u d e t o w a r d b a b y " s u b s c a l e o f t h e M A M A , f r o m which f o u r i t e m s w e r e d e r i v e d , has b e e n s h o w n to c o r r e l a t e highly with o t h e r i n d e p e n d e n t m e a s u r e s o f att i t u d e [10]. Relationship with depression (concurrent validity). F o u r h u n d r e d e i g h t y - t h r e e w o m e n c o m p l e t e d b o t h t h e E P D S a n d t h e M A Q . T h e m e a n age o f t h e s u b j e c t s was 28.3 y e a r s ( s o 5.5 years); 78 ( 1 6 % ) w e r e single p a r e n t s ; 197 ( 4 1 % ) h a d h a d unp l a n n e d p r e g n a n c i e s ; 212 ( 4 4 % ) w e r e first-time m o t h e r s ; a n d 449 ( 9 3 % ) s u b j e c t s w e r e white. I n 137 ( 2 8 % ) h o u s e h o l d s t h e m a i n w a g e e a r n e r was u n e m p l o y e d . A c c o r d i n g to c u r r e n t e m p l o y m e n t , 148 ( 3 1 % ) w e r e in social class I o r II, 130 ( 2 7 % ) social class I I I a n d 63 ( 1 3 % ) social classes I V a n d V; 262 ( 5 4 % ) o f t h e m o t h e r s w e r e n o t p l a n n i n g to r e t u r n to w o r k a f t e r a p e r i o d o f m a t e r n i t y leave; 118 ( 2 4 % ) h a d d e -
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Table I.--Cluster analysis of distribution of scores on the CIS-R and Maternal Attitudes Questionnaire (MAQ) for women with RDC major or minor depression (n = 80) Group 1 2 3 4
Number in group 20 35 11 14
Mean CIS-R score (95% CI) 20.0 27.1 29.0 37.4
(18.7-21.3) (26.1-28.1) (27.3-30.8) (36.0-38.9)
Mean MAQ score (95% CI) 6.8 (5.2-8.4) 4.9 (4.0-5.8) 14.8 (13.0-16.7) 10.5 (9.l-11.9)
livered by caesarian section; and 163 (34%) were still breast feeding at the time of the screening interview. One hundred forty-five (30%) subjects scored i>10 on the EPDS, including high scorers recruited in the fourth month; 129 (87%) agreed to a further interview using the CIS-R. Of those interviewed, 92 scored >12 on the CIS-R, 80 satisfying criteria for major or minor depression. Of these, 55 women (69%) agreed to enter the treatment trial, and 41 (75% of trial participants) complied with 3 months of treatment. The mean score on the MAQ in women scoring <10 on the EPDS was 2.4 (95% confidence interval 2.2-2.6) and for women scoring/>10 on the EPDS was 6.3 (95% confidence interval 5.6-7.0). Scores on the MAQ and on the EPDS showed a high degree of correlation (Pearson's correlation coefficient 0.60, p<0.001). There was a significant correlation between CIS-R score and total score on the MAQ (Pearson's correlation coefficient 0.50, p<0.001). These results indicate a strong association between depression and negative cognitions relating to motherhood. Among high scorers on the EPDS, the MAQ distinguished those with and without RDC major or minor depression at interview. Women with confirmed depression had a mean MAQ score of 7.7 (95% confidence interval 6.8-8.7). The nondepressed group had a mean score of 4.2 (95% confidence interval 3.4-5.1).
Heterogeneity of sample Table I shows the results of further analysis of the distribution of scores on the MAQ and the CIS-R for women with an RDC diagnosis of depression using K-means cluster analysis. The optimum number of clusters was found to be four; when a fifth cluster was added, the number of subjects (2) was unacceptably low. Analysis of variance between the four groups revealed significant differences in both total MAQ and CIS-R scores. Group 1 represents women with relatively mild depression and lower MAQ scores, similar to those of nondepressed women. Groups 2 and 3 have similar symptom scores, well above the morbidity threshold, but have widely different responses on the MAQ. The MAQ scores in group 2 are not significantly different from group 1. Group 3, on the other hand, has mean scores significantly higher than all other groups. Group 4 represents women with very high symptom scores and high MAQ scores. In summary, cluster analysis revealed a group of women (group 2) who, despite being depressed, did not have the maladaptive attitudes to motherhood that were in general associated with low mood. There were few other differences between the groups. Analysis of variance showed a significant age difference between group 1 (mean 28.3 years, 95% confidence limits 25.2-31.4 years) and group 4 (mean 25.1 years, 95% confidence limits
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21.9-28.4 years). Group 2 subjects were more likely to have had their babies admitted to a special care baby unit, [×2 (3) =8, p=0.03]. There were no significant differences between the groups in regard to: social class; social adversity (measured by the Social Maladjustment Scale [15] in a modified form used in another study of postnatal depression [3]); time of onset of depression (i.e., whether postnatal); marital status; unemployment in subject; unemployment in partner; parity; planned pregnancy; or several obstetric variables. The social characteristics of group 2 did not indicate a group with greater social adversity than other depressed women in the study. In 13 (37%), the head of household was currently unemployed; 9 (26%) had an unemployed partner; 24 (68%) were themselves unemployed; 3 (9%) were in social classes IV or V, according to current employment; and 8 (23%) were single mothers.
Effects o f attitudes on treatment response In those who received treatment, MAQ scores were significantly lower after 3 months (t-test for paired samples: pretreatment mean--8.0, posttreatment mean=4.8; difference of means=-3.15, 95% confidence interval -4.6 to -1.7). There was a highly significant correlation between changes in CIS-R score and changes in MAQ score after treatment (Pearson's correlation coefficient 0.43, p=0.006). Linear regression analysis of factors influencing treatment outcome showed no significant effect of initial total MAQ score or cluster group membership on posttreatment changes in CIS-R score in the whole treated group. There was no significant association between treatment type (drug/placebo or one/six sessions of counseling) and changes in MAQ score. DISCUSSION We have described specific attitudes associated with depression in postnatal women, using a new questionnaire to measure maternal cognitions. Our questionnaire was well accepted and completed without difficulty by the majority of subjects. Test-retest and internal reliability were high. Self-report measures of attitudes and beliefs are known to be mood-dependent [16]. However, this is the first time that cognitions on the specific theme of motherhood have been shown to be related to postnatal depression. Further analysis of the distribution of MAQ scores among depressed women indicates a separation of responses, suggesting that women with postnatal depression are cognitively heterogeneous. These findings may be important in understanding the etiology of postnatal depression. Studies of risk factors in postnatal depression have revealed conflicting findings, perhaps suggesting a heterogeneous population. Kumar and Robson, for example, studying the impact of the transition to motherhood on mental health in a group of first-time mothers, identified older age, thoughts of termination early in pregnancy, relative subfertility, and premature delivery as associated with postnatal depression [2]. Other studies on less selected samples have found an association between postnatal depression and indicators of social deprivation [17], some of which are similar to those found in depression in women with older children by Brown and Harris [18], although this has not been a consistent finding [19]. When several such risk fac-
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tors were included in a questionnaire designed to predict antenatally which women would become depressed postnatally, identification of cases was poor [20]. One explanation for these disparate findings is that some cases of depression postnatally are equivalent to depression arising at other times; in these cases, social risk factors are particularly important. Other cases of mood disorder in childbearing women may then represent a more specific postnatal depression, in which a particular cognitive pattern emerges in response to the specific stressor of motherhood. This group would be equivalent to those women described by Cooper and Murray [5] as becoming depressed postnatally but not at other times. This study has found evidence of cognitive differences between groups of women with depression in the postnatal period, but has not been able to characterize these groups further using the demographic variables available. In particular, group 2 (moderate depression, low MAQ scores) was expected to show evidence of social deprivation, but this was not demonstrated. The association with having a baby in a special care baby unit may, however, indicate a group that is depressed in response to specific stressors, although no other life events data are available to this study. It might also be predicted that group 3 (moderate depression, high MAQ scores) women are those whose antenatal cognitive style (high expectations, ambivalence about role change) makes them vulnerable to postnatal depression. O'Hara et al. [21] demonstrated a relationship between antenatal attributional style and the development of postnatal depression, although this was not confirmed in a later study [22]. The MAQ is not suitable for use antenatally in its present form but could be adapted to investigate prospectively which attitudes, if any, are predictive of depression postnatally. Although we were unable to demonstrate an effect of maternal attitude score on treatment response, the strong correlation between changes in CIS-R score and MAQ score suggest that changes in attitudes could be used in addition to more conventional assessments of emotional symptoms in monitoring treatment response in studies or clinical practice. The M A Q provides a quick and acceptable way of doing this, and may be of most use in studies of psychological intervention and outcome. Acknowledgment--Dr. Warner and Ms. Whitton were supported by a grant from Eli Lilly.
REFERENCES 1. Pitt B. "Atypical" depression following childbirth. Br J Psychiatry 1968;114:1325-1335. 2. Kumar R, Robson KM. A prospective study of emotional disorders in childbearing women. Br J Psychiatry 1984;144:35--47. 3. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993;163:27-31. 4. Cooper PJ, Murray L. Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept. Br J Psychiatry 1995;166:191-195. 5. Cooper PJ, Murray L. Paper presented at the Marc6 Society Biennial Conference, Cambridge, UK, September 1994. 6. Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitivebehavioural counselling in the treatment of postnatal depression. BMJ 1997;134:932-936. 7. Teti DM, Gelfland DM. Behavioural competence among mothers of infants in the first year: the mediational role of self-efficacy. Child Devel 1991;62:918-929.
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8. Astbury J. Making motherhood visible: the experience of motherhood questionnaire. J Reprod Infant Psychol 1994;12:79-88. 9. Ruble DN, Brooks-Gunn J, Fleming AS, Fitzmaurice G, Stangor C, Deutsch F. Transition to motherhood and the self: measurement, stability and change. J Pers Soc Psychol 1990;58:450-463. i0. Kumar R, Robson KM, Smith AMR. Development of a self administered questionnaire to measure maternal adjustment and maternal attitudes during pregnancy and after delivery. J Psychosom Res 1984;28:43-51. 11. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-786. 12. Murray L, Carothers A. The validation of the Edinburgh Post-natal Depression Scale on a Community Sample. Br J Psychiatry 1990;157:288-290. 13. Lewis G, Pelosi AJ, Araya R, Dunn G. Measuring psychiatric disorder in the community: a standardised assessment for use by lay interviewers. Psychol Med 1982;22:465-486. 14. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: rationale & reliability. Arch Gen Psychiatry 1978;35:773-782. 15. Clare AW, Cairns VE. Design, development and use of a standardised interview to assess social maladjustment and dysfunction in community studies. Psychol Med 1978;8:589-604. 16. Segal ZV, Shaw BF. Cognition in depression. Cogn Ther Res 1986;10:671-694. 17. Warner R, Appleby L, Whitton A, Faragher B. Demographic and obstetric risk factors for postnatal psychiatric morbidity. Br J Psychiatry 1996;168:607-611. 18. Brown GM, Harris TO. Social origins of depression. London: Tavistock 1978. 19. Murray D, Cox JL, Chapman G, Jones P. Childbirth: life event or start of a long-term difficulty? Br J Psychiatry 1995;166:595-600. 20. Appleby L, Gregoire A, Platz C, Prince M, Kumar R. Screening women for high risk of postnatal depression. J Psychosom Res 1994;38:539-545. 21. O'Hara MW, Rehm LP, Campbell SB. Predicting depressive symptomatology: cognitive-behavioural models and postpartum depression. J Abnorm Psychol 1982;91:457-461. 22. Cutrona CE. Causal attribution and perinatal depression. J Abnorm Psychol 1983;92:161-172.
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Appendix.--Maternal Attitudes Questionnaire Below is a series of statements about being a mother. In each case please circle the answer which most applies to you. This questionnaire is seeking your opinion--there are no right or wrong answers. 1. I think my baby is very demanding.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
Disagree 1
Strongly disagree 2
Disagree 0
Strongly disagree 0
Disagree 1
Strongly disagree 2
Disagree 0
Strongly disagree 0
2. I feel proud of being a mother.
Strongly agree 0
Agree 0
3. I am disappointed by motherhood.
Strongly agree 2
Agree 1
4. Having a baby has made me as happy as I expected.
Strongly agree 0
Agree 0
5. I sometimes regret having my baby.
Strongly agree 2
Agree 1
6. I am the only person who can look after my baby properly.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
7. To be a good mother, I should be able to cope well all the time.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
Disagree 1
Strongly disagree 2
8. If my baby is unwell or unhappy it is not my fault.
Strongly agree 0
Agree 0
9. I have resented not having enough time to myself since having my baby.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
10. My daily life has been no more difficult since my baby was born.
Strongly agree 0
Agree 0
Disagree 1
Strongly disagree 2
Disagree 0
Strongly disagree 0
11. If I find being a mother difficult, I feel a failure.
Strongly agree 2
Agree 1
12. If I love my baby I should want to be with him/her all the time.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
13. If other people help me look after my baby, I feel a failure.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
14. I resent the way my life has been restricted since having my baby.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
ELSEVIER
S0022.3999(97)00128-1
ATTITUDES TOWARD MOTHERHOOD IN POSTNATAL DEPRESSION: DEVELOPMENT OF THE MATERNAL ATTITUDES QUESTIONNAIRE RACHEL WARNER,* LOUIS APPLEBY,* ANNA WHITTON* and B R I A N F A R A G H E R t
(Received 23 December 1996; accepted 11 April 1997) Abslraet--This article describes the development of the Maternal Attitudes Questionnaire (MAQ), a 14-item self-report instrument measuring cognitions relating to role change, expectations of motherhood, and expectations of the self as a mother in postnatal women. This questionnaire was found to have good test-retest and internal reliability. In a large sample of women (n =483) at 6-8 weeks postpartum, scores on the questionnaire were highly correlated with scores on the Edinburgh Postnatal Depression Scale (EPDS) and the Revised Clinical Interview Schedule (CIS-R). Cluster analysis demonstrated that, among depressed women with similar symptom scores on the CIS-R, the MAQ discriminated a group with low MAQ scores and a group with high MAQ scores. This finding supports the hypothesis that women who are depressed postnatally are cognitively heterogeneous; such differences may be important in understanding the etiology and determining the treatment of postnatal depression. © 1997 Elsevier Science Inc.
Keywords: Attitudes measurement; Maternal attitudes; Postnatal depression. INTRODUCTION T e n to 15% of w o m e n experience a n o n p s y c h o t i c depressive illness following childbirth [1-3] but the etiological role of childbirth itself remains controversial. S o m e w o m e n d e v e l o p depression following childbirth but not o t h e r life events [4]; however, indicating a specific postnatal vulnerability that m a y be cognitive, social, or physiological. T h e i m p o r t a n c e of m a t e r n a l cognitions in postnatal depression is also suggested by two successful t r e a t m e n t trials using cognitive interventions [5, 6] and by two studies reporting a relationship b e t w e e n low m o o d and self-perceptions of m a t e r n a l c o m p e t e n c e [7, 8]. Nevertheless, there is little evidence on the relationship b e t w e e n postnatal depression and cognitive constructs such as self-image, role definition, and attitudes t o w a r d mothering, which are likely to be i m p o r t a n t in the transition to p a r e n t h o o d [9, 10]. T h e r e are three reasons to study m a t e r n a l cognitions in relation to postnatal de*School of Psychiatry and Behavioural Sciences, University of Manchester, Withington Hospital, Manchester, UK. tResearch Support Unit, Medical School, Manchester, UK. Address correspondence to: Louis Appleby, M.D., School of Psychiatry and Behavioural Sciences, University of Manchester, Withington Hospital, Nell Lane, Manchester M20 8LR, UK. Tel: 0161 291 4362; Fax: 0161 445 9263; E-mail: [email protected] 351
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p r e s s i o n . First, c o g n i t i o n s t y p i c a l o f p o s t n a t a l d e p r e s s i o n m a y b e m o r e useful t h a n e m o t i o n a l s y m p t o m s as a t a r g e t for p s y c h o l o g i c a l t r e a t m e n t s . S e c o n d , s u b g r o u p s of p o s t n a t a l l y d e p r e s s e d w o m e n m a y b e i d e n t i f i e d , differing in t h e c o g n i t i v e f e a t u r e s o f t h e i r illness; b y i m p l i c a t i o n , t h e y m a y also b e e t i o l o g i c a l l y d i s t i n c t - - t h o s e with p r o m i n e n t m a t e r n a l c o g n i t i o n s h a v i n g a specific p o s t n a t a l v u l n e r a b i l i t y , t h o s e witho u t such c o g n i t i o n s r e s e m b l i n g w o m e n with d e p r e s s i o n at o t h e r t i m e s a n d s h o w i n g s i m i l a r risk f a c t o r s such as social a d v e r s i t y . T h i r d , c o g n i t i v e style m a y b e a p r e d i c t o r of treatment response. We describe the development of a short questionnaire identifying the expectations o f a n d a t t i t u d e s t o w a r d m o t h e r h o o d t h a t o c c u r in r e l a t i o n to d e p r e s s i v e illness in t h e p o s t n a t a l p e r i o d . T h e q u e s t i o n n a i r e is t h e n u s e d to test t h e f o l l o w i n g h y p o t h eses: t h a t m a l a d a p t i v e c o g n i t i o n s c o n c e r n i n g m o t h e r h o o d a r e p r e s e n t in s o m e , b u t n o t all, w o m e n with p o s t n a t a l d e p r e s s i o n ; t h a t w o m e n w i t h o u t t y p i c a l m a t e r n a l cogn i t i o n s will b e c h a r a c t e r i z e d b y t h e p r o m i n e n c e o f social adversity; a n d t h a t w o m e n w i t h p r o m i n e n t m a l a d a p t i v e c o g n i t i o n s will b e m o s t r e s p o n s i v e to a c o g n i t i v e l y based treatment.
METHOD
Subjects Subjects were drawn from a large population taking part in a screening program intended to recruit women with postnatal depression to a treatment trial [6]. Women were approached in the immediate postpartum period, during visits on alternate days to two maternity units in South Manchester, and asked to agree to a home visit at 6 weeks postpartum to allow screening for depression using the Edinburgh Postnatal Depression Scale (EPDS) [11]. Exclusion criteria for screening were living outside the health district and inability to speak and read English. Over a 20-month recruitment period, 2978 women were eligible, of whom 2375 (80%) agreed to be screened. Women scoring I>10 on the EPDS, a threshold at which the sensitivity is 89% [12], were interviewed using the Revised Clinical Interview Schedule (CIS-R) [13], a structured interview assessing the severity and frequency of psychological symptoms in the week prior to interview. A score of >112 on the CIS-R indicates clinically significant morbidity. With the addition of questions relating to appetite, weight change, interest in usual activities, and duration of symptoms, the CIS-R can be used to make a clinical diagnosis of major or minor depression according to Research Diagnostic Criteria (RDC) [14]. Depressed subjects were asked to enter a trial in which they received either the antidepressant fluoxetine or placebo plus either one session or six sessions of a simple counseling derived from cognitive behavior therapy [6]. Two consecutive subsamples of women who were screened were asked to participate in the present study. The first (n=50) took part in the development and initial testing of the maternal attitudes questionnaire (MAQ). The second sample (n =483) was drawn from the main study population over a period of 4 months. During the first 3 months a systematic sample of 451 consecutive subjects was recruited, as described above; there were 16 refusals. In the fourth month this sample was supplemented with 32 subjects more likely to be depressed by collecting MAQ results only from women scoring t>10 on the EPDS.
Development of the questionnaire A review of previous literature [9, 10] and clinical experience with postnatal women suggested three areas of cognition that might be associated with depression postnatally: • expectations of motherhood; • expectations of the self as a mother; and • role conflicts. A pilot questionnaire was constructed consisting of 16 items relating to one or more of these areas. Four of the items were equivalent to items in the "attitude toward baby" subscale of the Maternal Adjustment and Maternal Attitude (MAMA) questionnaire [10], a self-administered questionnaire of 60 items relating to the marital relationship, maternal body image, attitudes toward sex, and attitudes toward the baby during pregnancy and after delivery. The new questionnaire consisted of a series of first person statements to which the subject was asked to indicate agreement or disagreement on a four-point response scale,
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similar to a Likert scale. The four-point response was used to prevent a noncommittal response set. Each item response was scored 0, 1, or 2, a higher score indicating agreement or strong agreement with "maladaptive" cognitions such as unrealistic expectations or those suggesting role conflict. A response set was avoided by wording the statements so that higher scores would sometimes indicate disagreement and sometimes agreement. A total score was obtained by adding individual item scores. The questionnaire used in the main study and the scoring of individual items are given in the Appendix. Fifty women completed the pilot questionnaire and were asked to comment on any questions that they thought were ambiguous or irrelevant. Test-retest reliability was measured at 1 week by sending the same women the questionnaire by post. This interval was expected to be long enough to prevent recall of previous responses but short enough to preclude major changes in mood and attitudes. Following the pilot study, two items were removed from the first version of the questionnaire because women reported that they were difficult to understand or answer. These items were: "I would like to have more children" and "People have to learn to be good mothers, it does not come naturally." Internal reliability and the relationship with depression were examined using the 14-item questionnaire, which was given to the main sample (n=483).
Statistical analysis The relationships between scores on EPDS or CIS-R and the maternal attitudes questionnaire were evaluated using scatterplots and correlation coefficients. Naturally occurring subgroups among the subjects with major or minor depression were sought using K-means cluster analysis; differences between identical clusters were examined using one-way analyses of variance for continuous measures and chisquare tests for categorical measures. The effect of attitudes scores on treatment response was assessed as part of an examination of several possible predictor variables using multiple linear regression methods: changes in CIS-R score at 3 months was used as the dependent variable, with total MAQ score as one of the independent variables.
RESULTS
Reliability Test-retest reliability.
Thirty-five ( 7 0 % ) o f t h e initial p i l o t s a m p l e r e t u r n e d the q u e s t i o n n a i r e o n the s e c o n d occasion. F o r i n d i v i d u a l scale items, n o significant c h a n g e s in r e s p o n s e s w e r e f o u n d b e t w e e n the t w o testing o c c a s i o n s using a W i l c o x o n p a i r e d - s a m p l e r a n k - s u m test. T h e m e a n c h a n g e in the t o t a l s c o r e was 0.0 ( 9 5 % r e f e r e n c e r a n g e _+4.6). Internal reliability. T h e v a l u e o f t h e s t a n d a r d i z e d r e l i a b i l i t y coefficient for t h e 14i t e m q u e s t i o n n a i r e was 0.84, i n d i c a t i n g a high level o f i n t e r n a l consistency.
Validity T h e i n s t r u m e n t has c o n s i d e r a b l e face validity, the initial list o f q u e s t i o n n a i r e i t e m s b e i n g d e r i v e d f r o m t w o sources: (1) clinical e x p e r i e n c e o f w o r k i n g with w o m e n suffering f r o m p o s t n a t a l d e p r e s s i o n , a n d (2) a v a i l a b l e r e s e a r c h e v i d e n c e . T h e " a t t i t u d e t o w a r d b a b y " s u b s c a l e o f t h e M A M A , f r o m which f o u r i t e m s w e r e d e r i v e d , has b e e n s h o w n to c o r r e l a t e highly with o t h e r i n d e p e n d e n t m e a s u r e s o f att i t u d e [10]. Relationship with depression (concurrent validity). F o u r h u n d r e d e i g h t y - t h r e e w o m e n c o m p l e t e d b o t h t h e E P D S a n d t h e M A Q . T h e m e a n age o f t h e s u b j e c t s was 28.3 y e a r s ( s o 5.5 years); 78 ( 1 6 % ) w e r e single p a r e n t s ; 197 ( 4 1 % ) h a d h a d unp l a n n e d p r e g n a n c i e s ; 212 ( 4 4 % ) w e r e first-time m o t h e r s ; a n d 449 ( 9 3 % ) s u b j e c t s w e r e white. I n 137 ( 2 8 % ) h o u s e h o l d s t h e m a i n w a g e e a r n e r was u n e m p l o y e d . A c c o r d i n g to c u r r e n t e m p l o y m e n t , 148 ( 3 1 % ) w e r e in social class I o r II, 130 ( 2 7 % ) social class I I I a n d 63 ( 1 3 % ) social classes I V a n d V; 262 ( 5 4 % ) o f t h e m o t h e r s w e r e n o t p l a n n i n g to r e t u r n to w o r k a f t e r a p e r i o d o f m a t e r n i t y leave; 118 ( 2 4 % ) h a d d e -
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Table I.--Cluster analysis of distribution of scores on the CIS-R and Maternal Attitudes Questionnaire (MAQ) for women with RDC major or minor depression (n = 80) Group 1 2 3 4
Number in group 20 35 11 14
Mean CIS-R score (95% CI) 20.0 27.1 29.0 37.4
(18.7-21.3) (26.1-28.1) (27.3-30.8) (36.0-38.9)
Mean MAQ score (95% CI) 6.8 (5.2-8.4) 4.9 (4.0-5.8) 14.8 (13.0-16.7) 10.5 (9.l-11.9)
livered by caesarian section; and 163 (34%) were still breast feeding at the time of the screening interview. One hundred forty-five (30%) subjects scored i>10 on the EPDS, including high scorers recruited in the fourth month; 129 (87%) agreed to a further interview using the CIS-R. Of those interviewed, 92 scored >12 on the CIS-R, 80 satisfying criteria for major or minor depression. Of these, 55 women (69%) agreed to enter the treatment trial, and 41 (75% of trial participants) complied with 3 months of treatment. The mean score on the MAQ in women scoring <10 on the EPDS was 2.4 (95% confidence interval 2.2-2.6) and for women scoring/>10 on the EPDS was 6.3 (95% confidence interval 5.6-7.0). Scores on the MAQ and on the EPDS showed a high degree of correlation (Pearson's correlation coefficient 0.60, p<0.001). There was a significant correlation between CIS-R score and total score on the MAQ (Pearson's correlation coefficient 0.50, p<0.001). These results indicate a strong association between depression and negative cognitions relating to motherhood. Among high scorers on the EPDS, the MAQ distinguished those with and without RDC major or minor depression at interview. Women with confirmed depression had a mean MAQ score of 7.7 (95% confidence interval 6.8-8.7). The nondepressed group had a mean score of 4.2 (95% confidence interval 3.4-5.1).
Heterogeneity of sample Table I shows the results of further analysis of the distribution of scores on the MAQ and the CIS-R for women with an RDC diagnosis of depression using K-means cluster analysis. The optimum number of clusters was found to be four; when a fifth cluster was added, the number of subjects (2) was unacceptably low. Analysis of variance between the four groups revealed significant differences in both total MAQ and CIS-R scores. Group 1 represents women with relatively mild depression and lower MAQ scores, similar to those of nondepressed women. Groups 2 and 3 have similar symptom scores, well above the morbidity threshold, but have widely different responses on the MAQ. The MAQ scores in group 2 are not significantly different from group 1. Group 3, on the other hand, has mean scores significantly higher than all other groups. Group 4 represents women with very high symptom scores and high MAQ scores. In summary, cluster analysis revealed a group of women (group 2) who, despite being depressed, did not have the maladaptive attitudes to motherhood that were in general associated with low mood. There were few other differences between the groups. Analysis of variance showed a significant age difference between group 1 (mean 28.3 years, 95% confidence limits 25.2-31.4 years) and group 4 (mean 25.1 years, 95% confidence limits
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21.9-28.4 years). Group 2 subjects were more likely to have had their babies admitted to a special care baby unit, [×2 (3) =8, p=0.03]. There were no significant differences between the groups in regard to: social class; social adversity (measured by the Social Maladjustment Scale [15] in a modified form used in another study of postnatal depression [3]); time of onset of depression (i.e., whether postnatal); marital status; unemployment in subject; unemployment in partner; parity; planned pregnancy; or several obstetric variables. The social characteristics of group 2 did not indicate a group with greater social adversity than other depressed women in the study. In 13 (37%), the head of household was currently unemployed; 9 (26%) had an unemployed partner; 24 (68%) were themselves unemployed; 3 (9%) were in social classes IV or V, according to current employment; and 8 (23%) were single mothers.
Effects o f attitudes on treatment response In those who received treatment, MAQ scores were significantly lower after 3 months (t-test for paired samples: pretreatment mean--8.0, posttreatment mean=4.8; difference of means=-3.15, 95% confidence interval -4.6 to -1.7). There was a highly significant correlation between changes in CIS-R score and changes in MAQ score after treatment (Pearson's correlation coefficient 0.43, p=0.006). Linear regression analysis of factors influencing treatment outcome showed no significant effect of initial total MAQ score or cluster group membership on posttreatment changes in CIS-R score in the whole treated group. There was no significant association between treatment type (drug/placebo or one/six sessions of counseling) and changes in MAQ score. DISCUSSION We have described specific attitudes associated with depression in postnatal women, using a new questionnaire to measure maternal cognitions. Our questionnaire was well accepted and completed without difficulty by the majority of subjects. Test-retest and internal reliability were high. Self-report measures of attitudes and beliefs are known to be mood-dependent [16]. However, this is the first time that cognitions on the specific theme of motherhood have been shown to be related to postnatal depression. Further analysis of the distribution of MAQ scores among depressed women indicates a separation of responses, suggesting that women with postnatal depression are cognitively heterogeneous. These findings may be important in understanding the etiology of postnatal depression. Studies of risk factors in postnatal depression have revealed conflicting findings, perhaps suggesting a heterogeneous population. Kumar and Robson, for example, studying the impact of the transition to motherhood on mental health in a group of first-time mothers, identified older age, thoughts of termination early in pregnancy, relative subfertility, and premature delivery as associated with postnatal depression [2]. Other studies on less selected samples have found an association between postnatal depression and indicators of social deprivation [17], some of which are similar to those found in depression in women with older children by Brown and Harris [18], although this has not been a consistent finding [19]. When several such risk fac-
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tors were included in a questionnaire designed to predict antenatally which women would become depressed postnatally, identification of cases was poor [20]. One explanation for these disparate findings is that some cases of depression postnatally are equivalent to depression arising at other times; in these cases, social risk factors are particularly important. Other cases of mood disorder in childbearing women may then represent a more specific postnatal depression, in which a particular cognitive pattern emerges in response to the specific stressor of motherhood. This group would be equivalent to those women described by Cooper and Murray [5] as becoming depressed postnatally but not at other times. This study has found evidence of cognitive differences between groups of women with depression in the postnatal period, but has not been able to characterize these groups further using the demographic variables available. In particular, group 2 (moderate depression, low MAQ scores) was expected to show evidence of social deprivation, but this was not demonstrated. The association with having a baby in a special care baby unit may, however, indicate a group that is depressed in response to specific stressors, although no other life events data are available to this study. It might also be predicted that group 3 (moderate depression, high MAQ scores) women are those whose antenatal cognitive style (high expectations, ambivalence about role change) makes them vulnerable to postnatal depression. O'Hara et al. [21] demonstrated a relationship between antenatal attributional style and the development of postnatal depression, although this was not confirmed in a later study [22]. The MAQ is not suitable for use antenatally in its present form but could be adapted to investigate prospectively which attitudes, if any, are predictive of depression postnatally. Although we were unable to demonstrate an effect of maternal attitude score on treatment response, the strong correlation between changes in CIS-R score and MAQ score suggest that changes in attitudes could be used in addition to more conventional assessments of emotional symptoms in monitoring treatment response in studies or clinical practice. The M A Q provides a quick and acceptable way of doing this, and may be of most use in studies of psychological intervention and outcome. Acknowledgment--Dr. Warner and Ms. Whitton were supported by a grant from Eli Lilly.
REFERENCES 1. Pitt B. "Atypical" depression following childbirth. Br J Psychiatry 1968;114:1325-1335. 2. Kumar R, Robson KM. A prospective study of emotional disorders in childbearing women. Br J Psychiatry 1984;144:35--47. 3. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993;163:27-31. 4. Cooper PJ, Murray L. Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept. Br J Psychiatry 1995;166:191-195. 5. Cooper PJ, Murray L. Paper presented at the Marc6 Society Biennial Conference, Cambridge, UK, September 1994. 6. Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitivebehavioural counselling in the treatment of postnatal depression. BMJ 1997;134:932-936. 7. Teti DM, Gelfland DM. Behavioural competence among mothers of infants in the first year: the mediational role of self-efficacy. Child Devel 1991;62:918-929.
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8. Astbury J. Making motherhood visible: the experience of motherhood questionnaire. J Reprod Infant Psychol 1994;12:79-88. 9. Ruble DN, Brooks-Gunn J, Fleming AS, Fitzmaurice G, Stangor C, Deutsch F. Transition to motherhood and the self: measurement, stability and change. J Pers Soc Psychol 1990;58:450-463. i0. Kumar R, Robson KM, Smith AMR. Development of a self administered questionnaire to measure maternal adjustment and maternal attitudes during pregnancy and after delivery. J Psychosom Res 1984;28:43-51. 11. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-786. 12. Murray L, Carothers A. The validation of the Edinburgh Post-natal Depression Scale on a Community Sample. Br J Psychiatry 1990;157:288-290. 13. Lewis G, Pelosi AJ, Araya R, Dunn G. Measuring psychiatric disorder in the community: a standardised assessment for use by lay interviewers. Psychol Med 1982;22:465-486. 14. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: rationale & reliability. Arch Gen Psychiatry 1978;35:773-782. 15. Clare AW, Cairns VE. Design, development and use of a standardised interview to assess social maladjustment and dysfunction in community studies. Psychol Med 1978;8:589-604. 16. Segal ZV, Shaw BF. Cognition in depression. Cogn Ther Res 1986;10:671-694. 17. Warner R, Appleby L, Whitton A, Faragher B. Demographic and obstetric risk factors for postnatal psychiatric morbidity. Br J Psychiatry 1996;168:607-611. 18. Brown GM, Harris TO. Social origins of depression. London: Tavistock 1978. 19. Murray D, Cox JL, Chapman G, Jones P. Childbirth: life event or start of a long-term difficulty? Br J Psychiatry 1995;166:595-600. 20. Appleby L, Gregoire A, Platz C, Prince M, Kumar R. Screening women for high risk of postnatal depression. J Psychosom Res 1994;38:539-545. 21. O'Hara MW, Rehm LP, Campbell SB. Predicting depressive symptomatology: cognitive-behavioural models and postpartum depression. J Abnorm Psychol 1982;91:457-461. 22. Cutrona CE. Causal attribution and perinatal depression. J Abnorm Psychol 1983;92:161-172.
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Appendix.--Maternal Attitudes Questionnaire Below is a series of statements about being a mother. In each case please circle the answer which most applies to you. This questionnaire is seeking your opinion--there are no right or wrong answers. 1. I think my baby is very demanding.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
Disagree 1
Strongly disagree 2
Disagree 0
Strongly disagree 0
Disagree 1
Strongly disagree 2
Disagree 0
Strongly disagree 0
2. I feel proud of being a mother.
Strongly agree 0
Agree 0
3. I am disappointed by motherhood.
Strongly agree 2
Agree 1
4. Having a baby has made me as happy as I expected.
Strongly agree 0
Agree 0
5. I sometimes regret having my baby.
Strongly agree 2
Agree 1
6. I am the only person who can look after my baby properly.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
7. To be a good mother, I should be able to cope well all the time.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
Disagree 1
Strongly disagree 2
8. If my baby is unwell or unhappy it is not my fault.
Strongly agree 0
Agree 0
9. I have resented not having enough time to myself since having my baby.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
10. My daily life has been no more difficult since my baby was born.
Strongly agree 0
Agree 0
Disagree 1
Strongly disagree 2
Disagree 0
Strongly disagree 0
11. If I find being a mother difficult, I feel a failure.
Strongly agree 2
Agree 1
12. If I love my baby I should want to be with him/her all the time.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
13. If other people help me look after my baby, I feel a failure.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0
14. I resent the way my life has been restricted since having my baby.
Strongly agree 2
Agree 1
Disagree 0
Strongly disagree 0