Perfectionism dimensions in major postpartum depression

Journal of Affective Disorders 136 (2012) 17–25

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Perfectionism dimensions in major postpartum depression Estel Gelabert a, b, Susana Subirà a, Lluisa García-Esteve c, Purificación Navarro c, Anna Plaza c, Elisabet Cuyàs b, d, Ricard Navinés b, c, f, Mònica Gratacòs e, Manuel Valdés c, Rocío Martín-Santos b, c, f,⁎ a

Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain Neuropsychopharmacology Programe, IMIM-Parc de Salut Mar, Barcelona, Spain c Neuroscience Institute, Hospital Clínic, Universitat de Barcelona (UB), IDIBAPS, Barcelona, Spain d Universitat Autònoma de Barcelona, Spain e Genes and Disease Program, Center for Genomic Regulation (CRG-UPF), CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain f CIBERSAM, Barcelona, Spain b

a r t i c l e

i n f o

Article history: Received 20 July 2010 Received in revised form 12 August 2011 Accepted 24 August 2011 Available online 17 September 2011 Keywords: Perfectionism Frost Multidimensional Perfectionism Scale Neuroticism Pospartum depression 5-HTTLPR Stin2 VNTR

a b s t r a c t Background: Although perfectionism from a multidimensional perspective has generally been associated with depressive illness, there are not many studies on its role in major depression in the postnatal period. The aim of the present study was to explore the relationship between perfectionism dimensions using the Frost Multidimensional Perfectionism Scale (FMPS) and major postpartum depression. Methods: One-hundred-twenty-two women with major postpartum depression (SCID-I; DSM-IV) and 115 healthy postpartum women were evaluated using the FMPS, an instrument for the assessment of six perfectionism dimensions: concern over mistakes, personal standards, parental expectations, parental criticism, doubt about actions and organisation. Other variables were also considered: neuroticism, psychiatric history, social support, life events and genotype combinations according to serotonin transporter expression (5-HTTLPR and Stin2 VNTR polymorphisms). Results: The prevalence of high-perfectionism was higher in major postpartum depression group than in control group (34% vs. 11%; p b 0.001). Multivariate models confirmed high-perfectionism as an independent factor associated with major postpartum depression. Specifically, the highconcern over mistakes dimension increased over four-fold the odds of major depression in postpartum period. (OR = 4.14; 95% CI = 1.24– 13.81) Neuroticism, personal psychiatric history and 5-HTT low-expressing genotypes at one of the loci were also identified as independent factors. Conclusions: High-perfectionism, and particularly high-concern over mistakes is a personality dimension associated with major postpartum depression. The inclusion of perfectionism assessment, together with others factors, may be considered in order to improve the detection of women at risk of postpartum depression, in whom early intervention may be of benefit. © 2011 Elsevier B.V. All rights reserved.

1. Introduction Major postpartum depression is a major public health problem affecting approximately 7% of mothers (Garcia-Esteve et al.,

⁎ Corresponding author at: Psychiatry Department, Neuroscience Institute, Hospital Clinic, IDIBAPS, CIBERSAM, Villarroel, 170, 08036-Barcelona, Spain. E-mail address: [email protected] (R. Martín-Santos). 0165-0327/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2011.08.030

2003; Gavin et al., 2005). Postpartum depressed women suffer from functional impairment and decreased quality of life (Boyce, 1996; de Tychey et al., 2008) and their children often display impaired cognitive, emotional and social development (Goodman and Brand, 2008). Major postpartum depression episodes can be severe, and may have a chronic course in a considerable number of women (Ashman et al., 2008; Garcia-Esteve et al., 2007; Vliegen et al., 2010). Despite its negative consequences, the majority of postpartum

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depressed women is not diagnosed and treated (Gale and Harlow, 2003). In this sense, the study of risk factors for postpartum depression could help to identify those women at high risk, facilitating diagnosis and treatment. Several meta-analyses of the literature have identified some risk factors as having moderate to strong associations with postpartum depression such as personal and family psychiatric history, depression and anxiety during pregnancy, stressful life events and poor social support (Beck, 1996, 2001; O'Hara and Swain, 1996; Robertson et al., 2004). Although genetic factors are not considered in these meta-analyses, there is also increasing evidence from family and twin studies about a genetic contribution to the risk of postpartum depression (Forty et al., 2006; Murphy-Eberenz et al., 2006; Treloar et al., 1999). Additionally, new findings on molecular genetic studies have identified the role of polymorphic variations in the serotonin transporter (SLC6A4) gene in depression after childbirth, specifically the 5-HTTLPR and the VNTR polymorphisms (Binder et al., 2010; Costas et al., 2010; Sanjuan et al., 2008). Although the link between personality traits and vulnerability to depression is well established; less robust are the findings about personality and postpartum depression. Neuroticism is the only personality factor that appears in metaanalyses as moderately associated to postpartum depression (Robertson et al., 2004). Recent research has confirmed that well-known personality features (i.e. neuroticism, harm avoidance) also increased the vulnerability to depression in postpartum period (Boyce et al., 2001; Jones et al., 2010; Martín-Santos et al., submitted for publication; Verkerk et al., 2005). In this sense, the interest in the personality construct of perfectionism has grown markedly over the years (Flett and Hewit, 2002). Perfectionism is moderately heritable (Tozzi et al., 2004) and is defined as the setting of high standards paired with overly critical self-evaluation in pursuit of these standards (Frost et al., 1990). It seems to play an important role in the aetiology, maintenance and course of certain psychopathological problems more prevalent in women, including eating disorders, depression and anxiety (Nilsson et al., 2008; Shafran and Mansell, 2001). One of the major developments is that perfectionism has become viewed as a multidimensional construct. The Frost et al. (1990) Multidimensional Perfectionism Scale (FMPS) and the Hewitt and Flett (1991) Multidimensional Perfectionism Scale (HMPS) are the most widely used measures of perfectionism. The FMPS is composed of six dimensions: concern over mistakes (CM), personal standards (PS), parental expectations (PE), parental criticism (PC), doubt about actions (DA) and organisation (O). The HMPS includes three dimensions of perfectionism: self-oriented perfectionism (SOP), otheroriented perfectionism (OOP) and socially-prescribed perfectionism (SPP). Several researches showed that some dimensions of each perfectionism scale are more strongly associated with psychopathology than others (Bardone-Cone et al., 2007; Sassaroli et al., 2008), supporting the assumption that perfectionism from a multidimensional perspective contains both negative (maladaptive or unhealthy) and positive (adaptive or sound) facets (Hawkins et al., 2006; Stumpf and Parker, 2000; Terry-Short et al., 1995). Studies that have employed exploratory and confirmatory factor analyses have found empirical evidences for these two higher

order perfectionism factors: maladaptive evaluation concerns, which included CM, PE, PC, DA and SPP subscales and were positively correlated with depression and negative affectivity, and positive achievement striving, which included PS, O, SOP and OOP subscales and were positively correlated with positive affectivity (Bieling et al., 2004; Blankstein, 2002; Frost et al., 1993). It has been suggested that perfectionism could play a moderating role in relation to stress and psychopathology (Hewitt and Flett, 2002). Giving birth to a child acts as a stressful event in itself, associated with many biological and psychosocial changes (Riecher-Rösler and Rodhe, 2005), perfectionism could be considered as a possible risk factor for postpartum depression. Research concerning perfectionism from a multidimensional perspective and perinatal depression has already yielded interesting findings. Some components of perfectionism may be related to depressive symptoms in pregnancy (Dimitrovsky et al., 2002; Macedo et al., 2009). In the only study using FMPS on postpartum, concern over mistakes was the only perfectionism dimension positively associated to postpartum depressive symptoms retrospectively assessed (Mazzeo et al., 2006). In a related vein, the Blatt's self-criticism construct (Blatt et al., 1976) has been positively associated with postpartum depressive symptoms in both cross sectional (Vliegen et al., 2006; Vliegen and Luyten, 2008, 2009) and longitudinal studies (Besser et al., 2007; Priel and Besser, 1999, 2002). Self-criticism has been conceptually and empirically related to self-critical perfectionism, a maladaptive facet of perfectionism (Dunkley et al., 2003; Powers et al., 2004). Moreover, self-criticism has been found to predict both depression diagnosis and levels of depression more than 3 years later in a sample of postpartum depressed mother that was hospitalised in a mother–child unit (Vliegen et al., 2010). The aim of the present paper was to study the role of perfectionism dimensions using the FMPS in major postpartum depression. We hypothesised that high-perfectionism (and its dimensions) would be associated to major postpartum depression after controlling for other biopsychosocial factors described in the literature. 2. Methods1 2.1. Participants A case–control study was performed in a general teaching hospital. The case group consisted of 115 Caucasian women diagnosed with major postpartum depression (DSM-IV criteria) during the first 6 months 1 after delivery at the Perinatal Psychiatric Unit. The diagnosis of major depressive episode was made by using the Structured Clinical Interview for DSM-IV diagnosis (SCID-I/P) depression module 1 DSM-IV and CIE-10 define postpartum depression (PPD) as a major depressive episode with an onset within 4 and 6 weeks postpartum respectively. However, PPD is a term applied to depressions that are prevalent during the postpartum period, which is increasingly viewed as up to 1 year after childbirth in research and clinical practice (O'Hara, 2008; Riecher-Rösler and Rodhe, 2005). In this sense, some authors have suggested to consider the extension of postpartum onset specifier to 6 months for mood disorders in the next generation of DSM and ICD (Austin, 2010).

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(First et al., 1997). All depressed women were also assessed by a general clinical interview, the Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987), the Duke-UNK Functional Social Support Questionnaire (Duke-UNK; Broadhead et al., 1988) and the St. Paul Ramsey Life Experience Scale (St. Paul Ramsey; Paykel, 1983). Moreover, to avoid any state effect on personality assessments, the Multidimensional Perfectionism Scale (FMPS; Frost, et al., 1990) and the Eysenck Personality Questionnaire-R Short Scale (EPQ-RS; Eysenck and Eysenck, 2001) were administered after a complete remission of depressive symptomatology. The control group consisted of 122 Caucasian puerperal women, recruited at the Obstetric Unit of the same hospital, who did not develop a major postpartum depressive episode throughout the first 8 months follow-up. Controls were assessed at the 2nd day after delivery by the general clinical interview, the EPDS, Duke-UNK, the St. Paul Ramsey rating scales and completed the personality questionnaires FMPS and EPQ-RS. Women were followed-up for depressive symptoms with the EPDS at 8 weeks and 32 weeks of postpartum. All women who scored EPDS b 9 were considered as noncases of postpartum depression and were included as a control group. Women whose child died after birth, were younger than 18 years old, with depression during pregnancy or with severe difficulties in understanding and answering questionnaires were excluded. The study was approved by the Institution Clinical Research Ethics Committee. All women signed an informed consent for participation. Concerning the demographical characteristics of cases and controls samples, the mean (SD) age of women with major postpartum depression was 33.7 (SD = 4.10) and of women in the control group was 31.39 (SD = 4.10) (t = −4.143, P = 0.003). Ninety-six percent of women in both groups were married or were living with a stable partner (χ2 = 0.005, P = 0.942). Nineteen percent of cases attended primary school, 16.5% finished secondary school and 45% had a college degree. In the control group, 16%, 43% and 41% finished primary school, secondary school, and had a college degree, respectively (χ2 = 1.071, P = 0.585). Sixty percent of mothers in the depressed sample were primiparous and 78% had a vaginal delivery whereas 69% were first time mothers and 83% had a vaginal delivery in the control sample (χ2 = 2.020, P = 0.155 and χ2 = 1.191, P = 0.275). The mean (SD) of EPDS-score was 18.50 (SD =4.01) in the depressed group and 3.78 (SD =2.78) in the control group (t= 31.207, P b 0.001). 2.2. Clinical assessment A general clinical interview ad-hoc for the study that included socio-demographic data (i.e. age, marital status, job situation and financial situation), obstetric variables (parity and type of delivery) and personal and family history of psychiatric illness was used for clinical assessment. The SCID-I/P depression module (First et al., 1997) was used to confirm a DSM-IV major depressive episode. Excellent interrater reliability was achieved for the diagnosis of depression (overall kappa = 0.91). The EPDS is a well-known 10-item self-reported scale, with four possible responses and a total score from 0 to 30, used as a screening tool for postpartum depression. The

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Spanish validated version of the EPDS (Garcia-Esteve et al., 2003) was used to screen postpartum depression in the control group. All puerperal women with an EPDS b 9 were considered probable healthy puerperal controls. The cut-off of 9/10 of the Spanish validated version of the EPDS has showed a good psychometric properties (85.5% sensitivity, 95% CI = 79.5–90.3 and 85.3% specificity, 95% CI = 80.1–89.7) to diagnose major postpartum depression (Navarro et al., 2007). Perfectionism was assessed with the Spanish version of the FMPS (Gelabert et al., 2011a). It proved good internal consistency (α = 0.93) and temporal stability (ICC = 0.89). The FMPS is a 35 item questionnaire designed to measure six dimensions of perfectionism: Concern over mistakes (reflecting negative reactions to errors), personal standards (setting high standards of performance), doubts about actions (the tendency to doubt about one's ability), parental expectations (the belief that one's parents set very high standards), parental criticism (the belief that one's parents were overly critical) and organisation (the importance placed on orderliness). It was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The FMPS gives 6 subscales scores, as well as a total score. We used a categorical classification of perfectionism. According to the results obtained previously (Gelabert et al., 2011a), women scoring above P75 were considered to be high on perfectionism (or high on the corresponding perfectionism subscale). The Spanish version of the EPQ-RS (Eysenck and Eysenck, 2001) consists of 48 dichotomous items selected from the 100-item EPQ-R and evaluates the personality traits of neuroticism, extraversion and psychoticism. It showed good internal consistency (from α = 0.71 to 0.86 in women) and test–retest reliability (from 0.72 to 0.86). We used T-scores results in the analysis, according to normative data for a Spanish female population. High-extraversion, high-neuroticism, and high-psychoticism were defined by T scoresN 56 (Eysenck and Eysenck, 2001). The Spanish version of the St. Paul Ramsey scale (Baca-Garcia et al., 2007) was administered to assess life events during pregnancy. The outcome variable used in this study was dichotomous: b3 or ≥3 stressful life events during pregnancy. This scale had good interrater reliability (0.96) (Zalsman et al., 2006). The Spanish version of the Duke-UNK (Bellón et al., 1996) is an 11-item self-administered questionnaire used to evaluate perceived functional social support during pregnancy. It showed good internal consistency (α = 0.90) and test–retest reliability (ICC = 0.92). The item response options are on a 5point scale ranging from 1 (much less than I would like) to 5 (as much as I would like). Higher scores reflect higher perceived social support. We administered the Spanish validated version adding the item: “I have a relative who goes with me to the doctor”. Using the data of a large community study in postpartum women (Sanjuan et al., 2008), scores below P25 were used to define poor social support during pregnancy. 2.3. Genotyping Maternal peripheral blood (5–10 mL) was collected for genotype analyses in all participants. The Puregene DNA purification kit (Gentra Systems) was used to extract genomic

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2.4. Statistical analysis

DNA from peripheral blood samples. Two polymorphisms in SLC6A4 (also known as 5-HTT) were analysed, both of which affect the 5-HTT expression: 5-HTTLPR, a 44-base pair insertion/deletion in the promoter region, and STin2, a multi-allelic 17-base pair variable number of tandem repeats (VNTR) within intron 2. Alleles of the 5-HTTLPR polymorphism were termed S (short allele with the deletion) and L (long allele with the insertion); the L allele shows higher basal transcription than the S allele (Heils et al., 1996). Two main alleles of the STin2 VNTR polymorphism have been described: STin2.10 and STin2.12, with 10 or 12 repeats respectively. STin2.12 displays higher transcriptional activity than STin2.10 (Fiskerstrand et al., 1999; MacKenzie and Quinn, 1999). STin2 alleles with 7 and 7 repeats occur at very low frequencies, and thus they were eliminated from the statistical analysis. It has been shown experimentally that the combination of both polymorphisms (5-HTTLPR and Stin2 VNTR) strongly affect the transcriptional level of the 5-HTT gene (Hranilovic et al., 2004). Three types of 5-HTT genotype combinations (5-HTT-GC) were used for the statistical analysis: 1) HE, no low-expressing genotype at either of the loci (LL/12.12), 2) ME, low-expressing genotype at one of the loci (LL/12.10, LL/10.10, LS/12.12, SS/12.12) and 3) LE, low-expressing genotypes at both loci (LS/12.10, LS/10.10, SS/12.10, SS/10.10). 5-HTTLPR and 5-HTTVNTR genotyping was performed using PCR. Each reaction mixture contained: 1 × PCR Amplification buffer and 1 × PCR Enhancer solution (Invitrogen, Carlsbad, CA), 1.5 mM MgSO4, 300 μM dNTPs, 0.5 pmol of each primer, 0.5 U of Taq DNA polymerase (Invitrogen) and 50 ng of genomic DNA as template. PCRs were performed using the next pair of primers: FAM-5′-GGCGTTGCCGCTCTGAATGC-3′ and 5′GAGGACTGAGCTGGACAACAACCAC-3′ and FAM-5′-GTCAGTATCACAGG-CTGCGAG-3′ and 5′-TGTTCCTAGTCTTACGCCAGT-3′ for 35 cycles at 58 °C and at 60 °C as annealing temperatures for 5-HTTLPR and 5-HTTVNTR amplification, respectively. A 10-μL total reaction volume was used and, after PCR, the products of allelic specific amplifications (allele L, 528 bp; allele S, 484 bp for 5-HTTLPR; and allele 9, 250 bp; allele 10, 267 bp; and allele 12, 300 bp for 5-HTTVNTR) were detected on an automatic ABI 3730XL capillary sequencer and analysed by GeneMapper Software v3.5 (Applied Biosystem, Foster City, CA, USA).

Variables were described independently for cases and controls. Means (SD), absolute and relative frequencies were obtained for descriptive analyses. Comparisons between groups were analysed using the chi-square test or ttest for independent samples, with the Bonferroni correction applied as necessary. Multivariate logistic regression analysis for major postpartum depression (DSM-IV) was used with a backward selection strategy, including those variables with a probability to enter into the model less than or equal to 0.1, setting in a probability model less than or equal to 0.05 for not to exit. The regression exponential coefficients were interpreted as odds-ratios and 95% CI. Statistical significance was set at P b 0.05. Analyses were performed with SPSS (version 15.0) computer program. 3. Results 3.1. Perfectionism: differences between cases and controls Table 1 shows differences in perfectionism dimensions between cases and controls after controlling for multiple comparisons. The prevalence of high-perfectionism (FMPS total score) in major postpartum depression group was higher than control group (34% vs. 11%; P b 0.001). However, when dimensions of perfectionism were considered, women with postpartum depression were more often high-concern over mistakes, high-personal standards, high-parental criticism and high-doubt about actions subjects than non-depressed women. There were no differences in high-parental expectations and high-organisation between groups. 3.2. Other risk factors: differences between cases and controls Differences in other risk factors are shown in Table 2. Women with major postpartum depression were more likely to be high-neuroticism subjects (P b 0.001), to have a personal psychiatric history (P b 0.001), life events (P = 0.010), and a lower social support (P b 0.001) than the control group. Both polymorphisms were in Hardy–Weinberg equilibrium (5-HTTLPR P = 0.124; STin2 VNTR P = 0.518). Frequencies were similar to those reported for other Caucasian populations

Table 1 Differences between cases (N = 122) and controls (N = 115): perfectionism dimensions (FMPS).

FMPS: High-perfectionism (total score) High-concern over mistakes High-personal standards High-parental expectations High-parental criticism High-doubt about actions High-organisation

Major PPD N = 122

Controls N = 115

N (%)

N (%)

χ2

P

OR (95% CI)

41 41 30 29 46 27 49

12 9 14 19 14 6 38

18.308 23.645 6.036 1.940 20.409 14.130 1.292

b0.001 b0.001 0.014 0.165 b0.001 b0.001 0.256

4.35 5.96 2.35 1.56 4.37 5.16 1.36

Major PPD: major postpartum depression. FMPS: Frost Multidimensional Perfectionism Scale.

(33.6) (33.6) (24.6) (23.8) (37.7) (22.1) (40.2)

(10.4) (7.8) (12.2) (16.5) (12.2) (5.2) (33.0)

(2.14–8.80) (2.74–12.97) (1.16–4.71) (0.83–3.00) (2.238–8.52) (2.05–13.04) (0.80–2.31)

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Table 2 Differences between cases (N = 122) and controls (N = 115): personality traits, psychiatric history, life events and social support.

EPQ: (%) High-neuroticism High-extraversion High-psychoticism Psychiatric history: N (%) –Personal: –Family: Life events: ≥3 life events Social support N (%) Poor social support in pregnancy

Major PPD N = 122

Controls N = 115

N (%)

N (%)

χ2

P

OR (95% CI)

54 (44.3) 41 (33.6) 24 (19.7)

9 (7.8) 53 (46.1) 20 (17.4)

40.270 3.853 0.201

b 0.001 0.050 0.652

5.66 (2.93–10.92) 0.73 (0.53–1.00) 1.13 (0.66–1.93)

63 (51.6) 58 (47.5)

17 (14.8) 48 (41.7)

35.963 0.806

b 0.001 0.369

3.49 (2.18–5.96) 1.14 (0.86–1.15)

14 (11.5)

3 (2.6)

6.990

0.010

28 (24.3)

16.611

b 0.001

61 (50)

4.40 (1.30–14.91) 2.05 (1.42–2.97)

Major PPD: major postpartum depression.

concern over mistakes was the only perfectionism dimension associated to depression, with over a fourfold increase in the odds of having a major depressive episode in postpartum period. High-neuroticism, personal psychiatric history and 5-HTT genotype combinations (low expression genotype at one loci) were also confirmed as independent factors associated to major postpartum depression. The Hosmer–Lemershow test showed the goodness-fit of the two models (P N 0.05).

(Fan and Sklar, 2005). The 5-HTT-GC genotype frequency distribution in the two groups, postpartum depression, and control is shown in Fig. 1. HE genotype was less frequent in the major postpartum depression group, although the differences were not significant (χ2 = 2.58, P = 0.275). 3.3. Independent risk factors associated to major postpartum depression Table 3 shows the results of multivariate regression analyses. Major postpartum depression (DSM-IV criteria) was the dependent variable in both models. Independent variables were perfectionism dimensions, neuroticism, personal psychiatric history, life events and social support during pregnancy and 5-HTT-CG. Because of the differences in age of mothers between both samples, this variable also was included into logistic regression models. In model 1, high-perfectionism (total FMPS score) was included as a measure of global perfectionism and the results showed that high-perfectionism was associated with over a threefold increase in odds of major postpartum depression. In model 2, the six dimensions of perfectionism were included separately as independent variables. In this case, high-

4. Discussion The results of the present study showed a higher prevalence of high-perfectionism in major postpartum women than in healthy postpartum group, and supported our hypothesis of perfectionism as an independent personality trait associated with major postpartum depression. This association seems to be primarily attributable to high-concern over mistakes, a specific dimension of perfectionism. This association was independent from other well-known risk factors for postpartum depression, such as high neuroticism, psychiatric history, 5-HTT expression genotype combinations, social support, and life events.

Percentaje

5-HTT-CG distribution per group 90 80 70 60 50 40 30 20 10 0 Major postpartum depression group HE

ME

Healthy control group LE

Fig. 1. 5-HTT expression genotype distribution in cases (N = 122) and controls (N = 115). HE = non-low-expressing genotype at both loci; ME = low-expressing genotype at one loci; LE = low-expressing genotype at both loci.

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Table 3 Multiple logistic regression analysis of major postpartum depression (DSM-IV). B

SE

Wald

P

OR

Model 1 (perfectionism total score)⁎ High-FMPS 1.092 0.451 2.42 0.015 2.98 High-neuroticism 1.421 0.448 3.17 0.002 4.14 1.280 0.370 3.46 b 0.001 3.6 Personal psychiatric history 5-HTT-Genotype combination –ME 1.370 0.651 2.10 0.035 3.93 –LE 0.846 0.672 1.26 0.209 2.33 Constant − 2.372 0.676 − 3.51 b 0.001 Model 2 (perfectionism subscales)⁎ High-concern 1.420 0.615 2.31 0.021 over mistakes High-neuroticism 1.491 0.468 3.18 0.001 1.160 0.389 2.98 0.003 Personal psychiatric history 5-HTT-Genotype combination –ME 1.339 0.681 1.97 0.049 –LE 0.700 0.697 1.01 0.315 Constant − 2.391 0.710 − 3.37 b 0.001

95%CI 1.23–7.21 1.72–9.97 1.74–7.43

1.1–14.1 0.62–8.71

4.14 1.24–13.81 4.44 1.77–11.14 3.19 1.49–6.84

3.81 1–14.48 2.02 0.51–7.9

FMPS: Frost Multidimensional Perfectionism Scale; ME: low-expressing genotype at one loci; LE: low-expressing genotype at both loci. ⁎ Age, social support and stressful life events during pregnancy did not enter in the two final models. The Hosmer–Lemeshow test showed the good-fit of both models (P N 0.05).

The experience of being a mother is a stressful event associated with many biological and psychosocial changes, and some women with certain personality traits could find difficult to cope with them (Riecher-Rösler and Rodhe, 2005). In this sense, our work suggested that high-perfectionism is associated to major depressive episode in postpartum period. Moreover, postpartum depressive women had more often high standards of performance accompanied by overly critical evaluations of one's behaviour, with a sense of doubt about the quality of one's performance and place considerable value on their parents' evaluations. These findings are in agreement with the emerging role of perfectionism, from a multidimensional perspective, as a personality factor related to the aetiology, maintenance and course of depression. The association between major postpartum depression and perfectionism, using total scores on the FMPS, was consistent with previous studies in non-childbearing samples (Cheng et al., 1999; Khawaja and Armstrong, 2005; Stöeber, 1998). In respect to the concern over mistakes and doubt about actions FMPS dimensions, a moderate association has been found with reported depressive symptoms in postpartum (Mazzeo et al., 2006) and in non-childbearing major depression (Cox et al., 2002; Enns et al., 2001). In this line, postpartum depressive symptoms have been also associated to self-criticism, conceptualised as harsh punitive evaluation of the self, often accompanied by guilt, feelings of unworthiness and self-recrimination (Besser et al., 2007; Priel and Besser, 1999, 2002; Vliegen et al., 2006; Vliegen and Luyten, 2008, 2009). This construct has been related to several of the maladaptive perfectionism dimensions, such as concern over mistakes and doubt about actions dimensions of the FMPS (Dunkley and Blankstein, 2000) and it

has been suggested as reflecting the self-critical perfectionism, a maladaptive form of perfectionism associated to depression symptoms (Dunkley et al., 2003; Powers et al., 2004). The role of parental expectations and parental criticism in depressive illness is not as consistent as the two previous FMPS dimensions; however, both parental dimensions represent maladaptive perfectionism (Hawkins et al., 2006). Major depressed patients obtained higher scores in parental expectations and parental criticism than non-depressed controls (Sassaroli et al., 2008). Supporting our results, parental expectations failed to be associated with depressive symptoms in a depressed sample (Enns et al., 2001) as well as in a college sample (Frost et al., 1990). As regards the personal standards dimension, its role in depression is less clear. Some studies have shown small but significant positive correlations between personal standards and depression in non-clinical samples (Cox et al., 2002; Enns et al., 2001), but not in clinical depression (Bulik et al., 2003; Sassaroli et al., 2008). Moreover, it has been negatively associated with postpartum depressive symptoms (Mazzeo et al., 2006). In fact, this subscale seems to contain both adaptive and maladaptive aspects of perfectionism (Hawkins et al., 2006). Standard setting is suggested to be related to psychopathology when meeting those standards is necessary for maintaining a sense of selfworth, and some items of the personal standards dimension seem to capture a self-evaluation component (Di Bartolo et al., 2004; Sassaroli et al., 2008). Finally, in the present research, the tendency to be highly organised neat and systematic, was not significantly related with major postpartum depression. Although it might seem counter-intuitive, the results are consistent with previous research in which the organisation subscale has been widely considered as a functional dimension of perfectionism (Hawkins et al., 2006) with no association with depression (Cox et al., 2002; Enns et al., 2002; Frost et al., 1990; Khawaja and Armstrong, 2005; Stöeber, 1998). In the same line, it was found that there were no differences in the organisation item score of the Vulnerable Personality Style Questionnaire (VPSQ; Boyce et al., 2001) between women with and without major postpartum depression (Gelabert et al., 2011b). Despite the associations between major postpartum depression and some dimensions of perfectionism, regression analyses results suggested that major postpartum depression may be accounted for by a specific aspect of perfectionism, high-concern over mistakes. Similar findings were obtained for postpartum depressive symptoms (Mazzeo et al., 2006) and they were also consistent with the results of a multivariate structural analysis in a twin-population study (Tozzi et al., 2004), in which concern over mistakes was suggested to be the more central feature of perfectionism. Additionally, our study also supported the relationship between neuroticism and postpartum depression (Jones et al., 2010; Verkerk et al., 2005). Although previous research has related neuroticism and perfectionism (Enns et al., 2005), the results of the study suggest that they are independent associated factors, so both of them must be considered. Supporting previous research, women with psychopathological antecedents may be at risk of developing depression in postpartum (Garcia-Esteve et al., 2008; Milgrom et al., 2008; Robertson et al., 2004). Moreover, the relevance of genetic factors also emerged. It is known that genetic factors may be relevant to the onset of mood disorders after delivery,

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with a suggested heritability of 38% (Treloar et al., 1999). High-expression 5-HTT genotypes (based on 5-HTTLPR and STin2 VNTR) were associated in a dose–response fashion with major postpartum depression at 8 weeks (Sanjuan et al., 2008). A trend toward higher levels of depressive symptoms was also reported in women from the SL/LL group in comparison to the low-expression group SS at 6 weeks postpartum (Doornbos et al., 2009). These findings have been explained as a higher sensitivity of the high-expression genotypes for the decrease in cerebral tryptophan availability in early postpartum period (Baïlara et al., 2006; Moreno et al., 2002; Neumeister et al., 2006). Contrary to our hypothesis, the lack of association between the high expression genotypes and major postpartum depression in our study may be related to the small sample size; moreover, we considered all major depressive episodes during six month postpartum period and the acute decline in tryptophan availability occurs after delivery, suggesting that the aetiological mechanisms for early vs. later postpartum depression could be different. A strength of the study is that perfectionism has been studied from a multidimensional perspective, using the FMPS, in major postpartum depression evaluated through a structured clinical interview according to DSM-IV criteria. An important point is that personality traits were assessed after recovery in the postpartum depression group, so the results were not affected by the current depressive episode. Furthermore, a study designed to explore the stability of perfectionism among patients with major depression showed its persistence after recovery, suggesting that perfectionism is not a simple state effect associated with the active phase of illness and it could serve as a risk factor for depression (Cox and Enns, 2003). However, the study has some limitations. Although the intense association observed between perfectionism and major postpartum depression, this trait only affected to the third part of major postpartum women. The cross-sectional design prevents us from knowing the direction of the different associations found between perfectionisms and other factors in postpartum major depression patients. We did not exclude women with a history of major depression before this pregnancy; however, perfectionism seems to be stable over time and persists after recovery from a depressive episode (Cox and Enns, 2003). The lack of a control group of non-childbearing depression women does not allow us to know if perfectionism may be a specific risk factor for depression in the postpartum period. In summary, the inclusion of perfectionism assessment, particularly a high level of concern over mistakes in performance, together with others factors such as high neuroticism and personal psychiatric history, may be considered in order to improve the detection of women at risk of postpartum depression, in whom early intervention may be of benefit. Role of funding source Neither institution had a further role in the study design; the collection, analysis or interpretation of the data; the writing of the report; or the decision to submit the paper for publication.

Conflicts of interests No conflict declared.

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Acknowledgments This study has been partially supported by grants: Instituto Carlos III (GO3/184), FIS: PI041880, FIS: P1052565, Fundació La Marató TV3 (011910); SXM2006/02 from the Convocatoria d'Ajuts a treballs d'investigació sobre el sexisme (Conveni UAB-DURSI), and Generalitat de Catalunya (2009 SGR/1435).

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