Postpartum depression, suicidality, and mother-infant interactions

Arch Womens Ment Health (2009) 12:309–321 DOI 10.1007/s00737-009-0105-2 ORIGINAL CONTRIBUTION Postpartum depression, suicidality, and mother-infant interactions Ruth Paris & Rendelle E. Bolton & M. Katherine Weinberg Received: 21 November 2008 / Accepted: 17 August 2009 / Published online: 29 August 2009 # Springer-Verlag 2009 Abstract To date, few studies have examined suicidality in women with postpartum depression. Reports of suicidal ideation in postpartum women have varied (Lindahl et al. Arch Womens Ment Health 8:77–87, 2005), and no known studies have examined the relationship between suicidality and mother-infant interactions. This study utilizes baseline data from a multi-method evaluation of a home-based psychotherapy for women with postpartum depression and their infants to examine the phenomenon of suicidality and its relationship to maternal mood, perceptions, and mother-infant interactions. Overall, women in this clinical sample (n=32) had wide ranging levels of suicidal thinking. When divided into low and high groups, the mothers with high suicidality experienced greater mood disturbances, cognitive distortions, and severity of postpartum symptomotology. They also had lower maternal self-esteem, more negative perceptions of the mother-infant relationship, and greater parenting stress. During observer-rated mother-infant interactions, women with high suicidality were less sensitive and responsive to their infants’ cues, and their infants demonstrated less positive affect and involvement with their mothers. Implications for clinical practice and future research directions are discussed. against suicide in parents. Often this is true for women with young children. However, women with postpartum psychiatric difficulties, such as postpartum depression (PPD), stand out as unique from this finding. These women are thought to have a higher rate of suicidal ideation (Henshaw 2007). Postpartum depression is a serious mental health problem that has deleterious effects on the mother, the mother-infant relationship, and ultimately on infant development (Lyons-Ruth 2008; Murray and Cooper 1997; Weinberg and Tronick 1998). Given that postpartum depression was estimated recently to occur in as many as 19% of new mothers (Gavin et al. 2005), and that suicidal ideation is thought to be a common aspect of PPD, it is imperative to understand more about the population of women struggling with these problems and to study the impact of suicidality on parenting and the mother-infant relationship. Utilizing pre-treatment data from a research study evaluating a home-based intervention for mothers with postpartum depression and their infants, the present study examines the prevalence of suicidal ideation and explores its impact on mothers’ mood, perceptions of parenting, and interactions with their infants. Keywords Postpartum depression . Postpartum suicidal ideation . Mother-infant interactions Postpartum depression It is hypothesized that having a child, usually a positive life event, serves as protection against suicidal ideation (Adam 1990). Qin and Mortensen (2003) supported this theory by finding that the presence of children serves as a defense R. Paris (*) : R. E. Bolton : M. K. Weinberg Boston University School of Social Work, 264 Bay State Road, Boston, MA 02215, USA e-mail: rparis@bu.edu Identified as the most common complication of pregnancy and childbirth (Wisner et al. 2002), postpartum depression is in many ways similar in presentation to non-postpartum depression with symptoms such as sadness, agitation, extreme fatigue, preoccupation, and suicidal ideation (Cooper et al. 2007). PPD may also be characterized by anxiety, mental confusion, low maternal self-esteem, limited sense of self-efficacy with respect to parenting, and intense shame and guilt surrounding one’s experience of 310 depression (Beck and Indman 2005; Kendall-Tackett 2005). Additionally, women with PPD can exhibit greater psychomotor disturbances and cognitive impairments than those with non-postpartum depression (Bernstein et al. 2006; Teti and Gelfand 1997)–possibly as a result of the demands of caring for an infant (Cooper et al. 2007). Suicidal ideation is frequently seen in the context of PPD, (Lindahl et al. 2005) with the concomitant hopelessness, desperation, and preoccupation that are part of the desire to escape one’s current situation (Beck 2002). Some studies have examined prevalence of suicidal ideation in mothers of infants (Appleby 1991; Evans et al. 2001; Lindahl et al. 2005) but none have looked at its particular ramifications for the mother-infant relationship. Postpartum depression and the mother-infant relationship Relationships between depressed mothers and their infants are often characterized by impairments in the process of mutual regulation (Weinberg and Tronick 1998). Optimal maternal-infant interactions typically consist of positive affect, reciprocity, synchrony, and attunement (Slade et al. 2005). Cognitive and affective processes associated with postpartum depression, such as preoccupation, low maternal self-esteem, and suicidal ideation, can manifest in many ways in the mother-infant relationship. For example, mothers can be disengaged from infants, talk less, show fewer facial expressions, share less of their attention to an object, and touch their infants less frequently (Field et al. 2007; Weinberg et al. 2001). Chronic disruptions of the mutual regulatory interchange between mothers and infants strain attachment processes, impair infant social-relational learning and development, and interfere with the infant’s ability to regulate his or her physiological, affective, and interactional states (Brockington 2004; Teti 2000; Sokolowski et al. 2007). Infants of depressed mothers can show fewer affectively positive facial expressions and vocalization, more withdrawal, less attentiveness to the mother, decreased activity level, greater fussiness, and overall less engagement with people and objects (Field 2008; Feldman et al. 2009; Weinberg and Tronick 1998). In the long term, the quality of the early mother-infant relationship appears to predict aspects of child development, such as diverse forms of psychopathology, behavioral problems, and disruptions in cognitive abilities (Feldman and Eidelman 2009; Lyons-Ruth 2008; Milgrom et al. 2004; Righetti-Veltema et al. 2003). Suicidality and postpartum women Although the prevalence of suicidality is lower in postpartum women than in the overall population, new mothers R. Paris et al. around the world have reported thoughts of self-harm at varying rates (Lindahl et al. 2005). Evans et al. (2001) found that 5.4% of a group of English women who were 8 weeks postpartum reported suicidal thoughts on the Edinburgh Postnatal Depression Scale; 14.2% reported the same in a poor South African community (Cooper et al. 1999); and at the Mayo Clinic, 15% of women reported some thoughts of self harm at 6 weeks postpartum (Georgiopolous et al. 2001). Women hospitalized with a psychiatric disorder who have recently given birth are at a 70-fold risk of suicide for one year (Appleby et al. 1998). Importantly, those that made actual attempts to take their lives used more violent and lethal methods (e.g. jumping from a building, self incineration, or intentional traffic accidents) indicating high intent (Appleby 1991; Henshaw 2007; Högberg et al. 1994). In a 2002 report in the United Kingdom, suicide was found to be the leading cause of death for mothers in the postpartum year (Henshaw 2007). Many studies reviewed here have assessed suicidal ideation in the context of postpartum depression. If suicidality and depression are overlapping but distinct occurrences, the rates presented may be artificially low (Lindahl et al. 2005). Suicidality and the mother-infant relationship Suicidal ideation when co-occurring with postpartum depression shares many of the same symptoms, yet there are additional experiential aspects that can be detrimental to the mother and her relationship with her infant. People who are suicidal can cognitively distort a small stressor into a lethal one (Shea 2002). An overwhelming external stressor such as a pregnancy or the birth of a baby can precipitate feelings of hopelessness and trigger thoughts of self harm (Pollock and Williams 1998). Many mothers with PPD experience shame and humiliation in viewing themselves as the worst mothers in the world; they imagine that others see them this way as well. Such inner conflict can trigger suicidal thoughts for a woman who focuses on the ideas that her baby will be better off without her or that she may hurt her baby if she lives (Beck 2002). Additionally, suicidal people have demonstrated poor problem-solving abilities in the context of cognitive rigidity and an overall passive approach to dealing with life’s challenges. When struggling with thoughts of self-harm they are unable to generate many alternative solutions to problems (Pollock and Williams 2004). These problem solving deficits appear independent of mood, so improvement in depressive symptoms for mothers with postpartum depression will not necessarily improve their ability to solve dilemmas they face with their infants. Women who become depressed and suicidal in pregnancy or postpartum are unable to manage the stress of a new infant and have poor abilities to respond to the PPD, suicidality, and mother-infant interactions challenges of motherhood, specifically the day-to-day interactions with their baby. As described above, these interactions involve many instances of attunement and responsiveness depending on the needs of the infant. Performing these tasks with reduced hours of sleep, low energy, and preoccupation with depressive internal states is a feat of grand proportions for mothers with PPD. Although many manage to complete necessary caregiving tasks in a mechanical manner by accessing “maternal instincts” and empathy for their infant (Barr 2006), those who are suicidal are further hampered by their compromised ability to develop appropriate responses to their infants’ increasing demands (Noorlander et al. 2008). Often they are passive in their approaches, demonstrating hopelessness in their interactions with infants. It is possible that the more the mother is unable to care for her infant the more depressed and suicidal she becomes. For some mothers with PPD suicidal ideation has become part of the postpartum experience (Beck and Indman 2005). The main questions in the present study are the following: 1) What is the prevalence of suicidal ideation in a community clinical sample of mothers with postpartum depression? 2) How do mothers who score lower or higher on suicidal ideation appear on measures assessing emotional and cognitive functioning, maternal self-esteem, and parenting stress? 3) Do the mothers who are more suicidal appear different to observers on ratings of mother-infant interactions? Hypothesis #1: We anticipated that many women in this sample with PPD would have experienced a significant degree of suicidality, even though the vast majority had not been hospitalized due to the disorder. This was expected because of the high rate of suicidal thoughts and attempts at suicide that have been documented in women with postpartum psychiatric difficulties (Lindahl et al. 2005). Hypothesis #2: We also anticipated that these women would have experienced a range of symptoms associated with their PPD, and those who experienced greater distress would have felt more suicidal. This was expected because of the diverse nature of postpartum depression (Beck and Gable 2000; Beck and Indman 2005) and the possibility that severity of symptoms could lead to suicidal thoughts or actions. Given the cognitive, emotional, and relational difficulties experienced by suicidal individuals, we further anticipated that women’s higher scores on suicidality would also be associated with negative self-appraisal of a) mothering, b) the infant, and c) the mother-infant relationship. Hypothesis #3: Finally, mother-infant pairs where the mothers scored higher on suicidal ideation were expected to have more problems in mutual regulation. Specifically, we anticipated that mothers in these pairs would demonstrate less sensitivity and reciprocity in interactions and infants themselves would be less involved. 311 Method In this paper, we present data collected prior to treatment from a mixed method research project evaluating the effectiveness of a home-based mother-infant psychotherapy. The intervention, called Early Connections, is aimed at decreasing postpartum depression and mitigating its impact on the mother-infant relationship (Spielman 2002). During weekly home-visits to the mother and baby, typically lasting approximately 16 weeks, the Early Connections clinicians use psychotherapeutic techniques such as active listening, encouraging emotional expression, exploring relevant historical events, and focusing on the mother baby interactions, among others. The clinician moves back and forth between the mother’s past and her present relationship with her infant, always keeping in mind the baby’s socialemotional needs (Paris et al. 2009). In order to obtain a broad assessment of maternal functioning, participants completed self-report questionnaires which included five measures, administered prior to treatment, upon ending treatment, and 3 months following treatment. Most mothers additionally participated in pre and posttreatment video-taped sessions with their infants, and in a semi-structured post-treatment interview. In the present study baseline data from the pre-treatment self-report measures were examined to assess the prevalence of suicidal ideation. Second, women who scored lower and higher on suicidal ideation were compared on measures assessing emotional and cognitive functioning as well as maternal self-esteem and parenting stress. Finally, the two groups were compared on observer ratings of mother-infant interactions. Population and procedure Sample Thirty-five mother-infant dyads who were enrolled in the Early Connections Program participated in the study (there were 32 mothers, and 3 twin-dyads enrolled). Program participants were predominantly first time mothers mostly in their 30 s (mean age=32.5 years, range=23−42) who were referred to the Early Connections program by community providers (e.g. physicians, nurses, or social workers) due to depression, isolation, and extreme difficulties in parenting infants. Mean developmental age of babies was 16 weeks (median=12 weeks). All mothers enrolling in Early Connections between June of 2005 and July of 2007 were invited to participate in the research study. Program staff first asked the mothers if they would agree to be contacted by research staff; a research assistant then called those women who consented to being contacted in order to explain the research project and ask the women to participate. Upon agreeing to participate in the study, a trained research assistant then met with the participant at her home to obtain informed consent for study participa- 312 tion, in accordance with protocol approved by the University Institutional Review Board, and to begin the data collection process. Approximately 65% of all mothers enrolled in Early Connections during this two year period agreed to participate in the research study. Research participants were similar to non-participants with respect to age, level of education for mother or father, number of children, age of infant, and level of postpartum depression and suicidality at intake. Data collection During the initial visit with a trained research assistant, mothers completed a pre-treatment selfreport questionnaire packet comprising demographic questions and four standardized measures including, the Brief Symptom Inventory (Derogatis 1993), the Parenting Stress Index- Short Form (Abidin 1995), the Maternal Self-Report Inventory- Short Form (Shea and Tronick 1988) and the Dyadic Adjustment Scale (Spanier 1976; not reported on in this paper). Two 5-minute video-taped segments of interactions between the mother and infant were also completed if the mother assented. During the visit all 32 mothers completed the pre-treatment questionnaires, and 30 of the mother-infant dyads (including all three sets of twins) agreed to participate in the video-taping. Additionally, upon enrolling in the intervention, Early Connections program staff routinely collected demographic data and administered the Postpartum Depression Screening Scale (Beck and Gable 2000; described below) to all mothers; with participants’ consent, this information was shared for inclusion in the research protocol. Video-taping in the home, by a trained research assistant, consisted of 1) a 5-minute developmentally appropriate structured task-oriented segment such as asking the parent to guide the infant in following a rattle, and 2) a 5-minute unstructured interaction period, during which time the mothers were instructed to interact with their babies as they normally would without the use of any toys or other props. The video-taped interactions were coded individually by two trained research assistants using the Coding Interactive Behavior manual (CIB; Feldman 1998). Cronbach alpha reliability scores ranged between .63 and .98 for all but two of the video segments. The coders then discussed each video with an expert in infant development to reach consensus on items where any disagreements in ratings had occurred. The entire coding team met to reach consensus on the two videos with the most disagreements. These consensus scores were used in the data analyses. Measures Maternal mood and psychological functioning The Postpartum Depression Screening Scale (PDSS, Beck and Gable 2000) was used to assess mothers’ postpartum R. Paris et al. psychiatric difficulties. This multi-dimensional scale is a 35-item standardized measure designed to screen for clinical levels of postpartum depression. Items are scored on a 5-point scale, ranging from strongly disagree to strongly agree. In addition to yielding a total score, this measure also comprises 7 subscales, measuring sleeping / eating disturbances, anxiety / insecurity, emotional lability, mental confusion, loss of self, guilt / shame, and suicidal thoughts. Total scores for the measure can range from 35– 175, with scores ≥ 60 indicating significant levels of postpartum depression and scores≥80 indicating a positive screen for major postpartum depression. The PDSS has good internal reliability, content, and construct validity (Beck and Gable 2000). The suicidal thoughts subscale of the PDSS comprises five items assessing the degree to which the mother, 1) felt her baby would be better off without her, 2) wished she could leave this earth, 3) wanted to harm herself, 4) felt that death was the only way out, and 5) thought that she’d be better off dead. Possible scores on this subscale range from 5–25, with higher scores representing a greater degree of suicidal thinking. It is suggested that respondents scoring≥ 6 should be immediately assessed for suicide risk by a mental health professional. The Brief Symptom Inventory (BSI) is a short (53-item) version of the Symptom Checklist-90-R (Derogatis 1975), designed to assess a range of psychological symptoms tapping emotional, somatic, and interpersonal dimensions of distress. Items are scored on a 5-point scale ranging from strongly disagree to strongly agree, with total possible scores ranging from 0–212. This scale is comprised of 3 global indices to measure psychological distress, as well as 9 subscales assessing somatization, obsessive-compulsive symptoms (questions which largely tap into disturbances in cognitive functioning), interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. On the BSI, higher scores indicate greater psychological distress experienced by the respondent on each of the corresponding subscales as well as on the global indices of distress. The BSI has been used with a wide range of populations, and is known to have good reliability and validity (Derogatis 1993). Maternal perceptions The Maternal Self-Report InventoryShort Form (MSI-SF) (Shea and Tronick 1988) was used to examine participants’ self-esteem and self-perceptions related to parenting and motherhood. This 26-item scale is derived from the longer 100-item Maternal Self-Report Inventory, which has previously been used to evaluate maternal postpartum functioning (Weinberg et al. 2001). In addition to yielding a total score, the MSI-SF also yields scores on 5 separate domains which assess a mother’s perceptions of her caretaking abilities, her general ability PPD, suicidality, and mother-infant interactions and preparedness for her role as a mother, her acceptance of her baby, her expectations that she will have a positive relationship with her baby, and her feelings concerning labor and delivery. Higher scores indicate more positive perceptions and higher maternal self-esteem on each of these dimensions. Total scores can range from 26–130. Among non-depressed mothers, a mean score on the MSISF is approximately 105 (Weinberg et al. 2001; Weinberg, personal communication). The MSI has good concurrent, internal, and external validity and test-retest reliability (Shea and Tronick, 1988). The Parenting Stress Index-Short Form (PSI-SF) (Abidin 1995) is a 36-item measure used to assess stress related to parenting and maternal perceptions of infants/children. In addition to a total score, this measure also contains subscales to measure distress associated with parenting and being a parent (Parental Distress), perceptions that the child does not meet the parent’s expectations or that the interactions between parent and child are not reinforcing to the parent (referred to as Parent-Child Dysfunctional Interaction), and perceptions that the child’s behavior is difficult to manage (Difficult Child). On this scale, a total score≥90 indicates clinically significant levels of stress related to parenting, for which professional assistance is recommended. Although no study has directly assessed the validity of the short form, the full-length PSI has been used in many studies and has good internal and external validity (Abidin 1995). Coding of mother-infant interactions Mother-infant videotaped interactions were coded using a modified version of the Coding Interactive Behavior (CIB) manual (Feldman 1998). This measure is comprised of 42 items each rated on a 5-point scale that are aggregated into several composite scales, where higher scores indicate more evidence of the dimension being coded, regardless of whether this dimension is ideal for healthy mother-infant interactions. The CIB has been validated with healthy and at risk populations, as described by its author (Feldman 1998, 2003, 2007). In the present study, 26 items from the original manual relevant to this population and the age of the infants were used. Individual items were aggregated into composites measuring mothers’, infants’ and dyadic behaviors including: (a) maternal sensitivity and responsiveness (acknowledging, imitating, elaborating, parent gaze, positive affect, vocal appropriateness, appropriate range of affect, consistency of style, and resourcefulness), (b) maternal intrusiveness (physical manipulation/forcing and overriding-intrusiveness), (c) infant initiation and involvement (vocalization and initiation), (d) infant positive affect (child positive affect and peak affective involvement/alertness), (e) infant negative affect (child negative emotionality/fussiness and fatigue), and (f) dyadic reciprocity (dyadic reciprocity, adaptive-regulation, 313 and fluency), during both task-oriented and unstructured interactions (Feldman 2003). Composites previously developed by Feldman (2003) were used because of their reliability and our small sample size. Data analysis Univariate analyses were conducted to examine basic characteristics of the sample, including prevalence of postpartum depression and suicidal thoughts. Participants were then divided into two groups based on level of suicidality using a median split, where women scoring 12 and higher on the suicidal thoughts subscale of the PDSS were coded as moderate/high and women scoring below a 12 were coded as none/low. Six women in the none/low group scored a 5 on the subscale indicating no endorsement of suicidal ideation. Given the small sample size and for ease of communication in the tables and text the groups are referred to as Low Suicidality and High Suicidality. To assure that the low group indeed represented women with lower levels of suicidality, we examined each participant’s individual responses to the 5 items that comprise this subscale. Specifically, we wanted to assure that none of the women coded as low on suicidal thoughts had endorsed an item as a 5 (strongly agree), 4 (agree), or 3 (neither agree nor disagree). We found that women in the low suicidal group consistently endorsed items at a 1 (strongly disagree), with an occasional endorsement of a 2 (disagree). The exception was on the item “my baby would be better off without me,” where approximately 1/3 of the women in the group had endorsed this item with a higher score. Given that women with postpartum depression often feel that they are bad mothers, we considered a higher endorsement on this item coupled with a low endorsement on the remaining items in the subscale to still represent lower levels of suicidal thoughts. In contrast, participants in the high suicidality group frequently rated multiple items in the scale at a 3 or above, and rarely endorsed an item with a 1 or a 2. This method of dividing the group is also supported by the Early Connections clinicians’ use of the subscale, where mothers who frequently endorse items at 3 and above are considered high risk (Spielman, personal communication). Suicidal ideation is actively addressed with these mothers in the context of the treatment. Given the clinical support, we think that our method of separating the sample into high and low suicidality groups is acceptable. Bivariate analyses were then conducted to examine differences between women in the low and high suicidal thought groups. Independent sample t-tests were used to analyze differences between the groups in postpartum depression (PDSS), overall psychological distress (BSI), maternal self-esteem (MSI), parenting stress (PSI), and 314 mother-infant interactions (CIB). Exploratory subscale analyses were also conducted, mindful of the small sample size. Independent sample t-tests and chi-square analyses were used to analyze whether women in the two groups differed with respect to demographic characteristics. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) v.16.0. Results Demographics Demographics for the entire sample and each subgroup are reported in Table 1. No significant statistical differences were found between the low and high suicidality groups on any of the descriptive characteristics, including experience with motherhood (new vs. veteran mothers). Infants ranged in developmental age from 0 to 63 weeks at the time of program enrollment, correcting for prematurity, with a mean developmental age of 16 weeks. On average, mothers were 32.5 years old (SD=5.6 years; range 23–43 years) and 91.5% were either married or partnered. The sample was predominantly Caucasian and incomes ranged widely but those over $50,000 were in the majority. Most participants were well-educated, with over 80% of mothers having graduated college or obtained a graduate or professional degree. The majority of mothers had been working before their babies were born and most were also experiencing parenthood for the first time. Overall, this was a sample with few socioeconomic risk factors. Postpartum depression and suicidality The single identifiable risk factor for PPD in this sample was history of a mood disorder. Upon entering the Early Connections program, 62.5% of the mothers reported that they had a prior history of depression and 53% percent identified that they recently started medication for depression. The range of medications included antidepressants most frequently (e.g., paroxetine, sertraline, and buproprion), and on a less frequent basis anxiolytics (e.g., lorazepam, clonazepam, and alprazolam), mood stabilizers (e.g., lamotrigine and lithium Carbonate), and atypical anti-psychotics (quetiapine and respiridone). There were no differences between the low and high suicidality groups on history of depression or use of medications. Reports from program clinicians and the mothers themselves indicated that the vast majority had begun medication simultaneous to beginning the intervention. Typically, once their distress was noted by a medical provider they were offered anti-depressant medications and a referral for home-based dyadic treatment. At intake, most participants reported that they were not feeling R. Paris et al. the impact of the medication when they filled out the pretreatment questionnaire. All of the women entering the program had baseline postpartum depression scores above the symptomatic cut-off point, and most had scores above the cut-off point for clinical levels of postpartum depression (mean=114, SD=24, range=70−164). In order to answer our first research question regarding the prevalence of suicidal ideation we examined the Suicidal Thoughts subscale of the PDSS. The mean score for the entire sample was 11.75 (SD=5.6) indicating a moderate degree of suicidality overall. The scores ranged from 5–25, which included all possibilities on this subscale. In order to compare mothers who were lower and higher on suicidal thoughts we computed a median split, as decribed above. The low suicidality group, comprising 47% of the sample (n=15), had a mean score of 6.8 (SD=1.9; range= 5–11). Fifty-three% of mothers comprised the high suicidality group (n=17) which had a significantly higher mean score of 16.2 (SD=4.1; range=12–25, t=−8.42**) Mood and symptoms Table 2 demonstrates differences in mood and symptoms between the low and high suicidality groups, and provides a partial response to our second research question. The groups differed significantly on the total score of the PDSS. Exploratory analyses of the subscales revealed that they also differed significantly on varied aspects of postpartum depression. Specifically, those mothers higher in suicidal thoughts were experiencing more sleeping and eating problems, were feeling more anxious, emotionally labile and mentally confused, had experienced a greater loss of self, and felt greater guilt about their experience. Both groups had total depression scores that were in the clinically significant range, but the high suicidality group exhibited significantly greater severity in overall struggles attributable to postpartum depression. As hypothesized, the Global Severity Index of the BSI was significantly different between the two groups indicating greater overall self-reported psychopathology for the more suicidal women. Results from exploratory subscale analyses of the BSI were significantly different for six of the subscales. The high suicidality group was more depressed and anxious. They also scored significantly higher on the psychoticism and obsessive-compulsive subscales indicating greater distortions in thinking and cognitions. The high suicidality group was more interpersonally sensitive and tended to experience more somatic symptoms. Maternal perceptions Table 3 presents differences in maternal perceptions on the MSI and PSI between the two suicidality groups, and provides answers to the latter half of our second research question. On the MSI, both groups demonstrated lower maternal self-esteem than a typical PPD, suicidality, and mother-infant interactions 315 Table 1 Descriptive characteristics of mothers Race Caucasian Black Asian Latina Bi-Racial Annual Family Income $0–$24,999 $25,000–$49,999 $50,000–$74,999 $75,000–$99,999 $100,000 + Marital Status Married / Partnered Single Education Some High School Some College College Degree Graduate Degree Employment Prior to Birth Yes No Vocation Professional Paraprofessional Service Industry Student Homemaker First-time Mother Yes No History of Depression Yes No Medication for PPD at Intake Yes No Age of Baby at Intakec Age of Mother at Intake PDSS Total Score PDSS Suicidal Thoughts Score Total sample (N=32) Low suicidality a (n=15) High suicidality % % % n 78.1 6.3 9.4 3.1 25 2 3 1 3.1 1 17.2 6.9 31.0 13.8 31.0 5 2 9 4 9 90.6 9.4 n (n=17) n 80.0 ––– 13.3 6.7 12 ––– 2 1 76.5 11.8 5.9 ––– 13 2 1 ––– ––– ––– 5.9 1 25.0 8.3 33.3 8.3 25.0 3 1 4 1 3 11.8 5.9 29.4 17.6 35.3 2 1 5 3 6 29 3 93.4 6.7 14 1 88.2 11.8 15 2 3.1 15.6 21.9 59.4 1 5 7 19 6.7 13.3 20.0 60.0 1 2 3 9 ––– 17.6 23.5 58.8 ––– 3 4 10 78.1 21.9 25 7 80.0 20.0 12 3 76.5 23.5 13 4 50.0 15.6 3.1 9.4 21.9 16 5 1 3 7 53.3 13.3 ––– 6.7 26.7 8 2 ––– 1 4 47.1 17.6 5.9 11.8 17.6 8 3 1 2 3 71.9 28.1 23 9 80.0 20.0 12 3 64.7 35.2 11 6 64.5 35.5 20 11 64.3 35.7 9 5 64.7 35.3 11 6 53.1 46.9 Mean 17 15 SD 46.7 53.3 Mean 7 8 SD 58.8 41.2 Mean 10 7 SD 16.1 32.5 14.6 5.6 18.2 33.5 13.8 5.5 14.1 31.7 15.7 5.6 113.88 11.75 24.4 5.6 95.3 6.8 18.9 1.9 130.3 16.2 15.3 4.1 n=11 in low group for family income; n=14 in low group for history of depression a b None to Low Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 5<12 b Moderate to High Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 12≤25 c Baby age is corrected for prematurity 316 Table 2 Differences in mood and symptoms between mothers with low and high levels of suicidal thoughts during postpartum depression R. Paris et al. Self-report measure Low suicidality a (n=15) High suicidality Mean Mean Postpartum Depression Screening Scale PDSS Total Score 95.27 Selected Subscales Sleeping / Eating Problems 12.33 Anxiety / Insecurity 14.93 Emotional Lability 15.80 Mental Confusion 16.07 Loss of Self 14.53 Guilt / Shame 14.93 Brief Symptom Inventory Global Severity Index 1.18 Selected Subscales † p<0.10, * p≤0.05, ** p≤0.01 a None to Low Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 5<12 b Moderate to High Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 12≤25 Depression Anxiety Psychoticism Obsessive-Compulsive Hostility Phobic Anxiety Paranoid Ideation Somatization Interpersonal-Sensitivity Subscale SD b (n=17) t SD 18.86 130.29 15.33 −5.79** 5.69 3.28 2.93 4.42 3.46 5.09 18.47 19.12 19.82 19.53 19.47 19.53 5.27 2.85 2.93 2.92 2.79 4.13 −3.17** −3.86** −3.88** −2.54* −4.47** −2.82** 0.64 1.94 0.66 −3.27** 8.86 5.73 5.20 11.13 6.47 5.60 4.01 3.63 4.12 4.79 16.18 11.94 9.00 14.56 9.29 5.65 6.28 3.94 4.91 4.40 −3.60** −3.37** −2.83** −2.10* −1.74† 3.67 4.80 5.20 6.53 3.90 4.69 3.21 4.79 5.71 7.00 9.82 10.29 4.21 4.72 5.56 3.46 −1.41 −1.32 −2.83** −2.57* Table 3 Differences in maternal perceptions between mothers with low and high levels of suicidal thoughts during postpartum depression Maternal Self-Report Inventory MSI Total Score Selected Subscales Caretaking Ability Preparedness for Mothering Acceptance of Baby Expected Relationship with Baby Feelings Concerning Pregnancy Parenting Stress Index PSI Total Score Selected Subscales Parental Distress Parent-Child Dysfunctional Interactions Difficult Child Low suicidality a (n=15) High suicidality Mean Mean SD b (n=17) t SD 94.07 19.93 78.82 24.61 1.91† 20.47 30.80 11.40 18.73 12.67 5.79 5.69 2.64 4.15 4.82 17.47 24.24 9.29 14.59 13.24 6.56 8.17 3.24 5.95 5.17 1.36 2.60** 2.00† 2.26* −0.32 85.67 19.70 106.71 22.33 −2.81** 36.07 22.47 9.49 6.98 42.88 30.12 7.27 10.75 −2.30* −2.35* 27.13 8.11 33.71 12.26 −1.81† † p<0.10, * p≤0.05, ** p≤0.01 a None to Low Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 5<12 b Moderate to High Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 12≤25 PPD, suicidality, and mother-infant interactions 317 of their babies’ social signals and showed poorer ability to respond to them consistently. Additionally, mothers showed less positive affect and vocal appropriateness with their babies and focused their gaze less frequently on them. During structured interactions low and high suicidality mothers appeared more similar. Both groups demonstrated comparable difficulties in attuning to their infants consistently, but managed to stay in a reciprocal connection with them some of the time. The infants of the more suicidal mothers exhibited significantly less positive affect in the form of sounds or smiles and slightly more negative affect in the form of crying and fussing (marginal significance) in unstructured interactions. In addition, demonstrating the difficulties in the mutual regulatory process, babies initiated involvement with their highly suicidal mothers significantly less often in structured interactions and marginally so in unstructured ones. Infants of highly suicidal mothers were somewhat more passive and less engaged in the interactions. Observer ratings of parent intrusiveness and overall dyadic reciprocity were not significantly different between the two groups. sample of new mothers (see Weinberg et al. 2001). Those women higher in suicidality showed even lower total self esteem scores than the low suicidality group, statistically different at a trend level. In our exploratory subscale analyses we anticipated that the highly suicidal mothers would endorse more negative self-appraisal and greater distortion regarding their relationships with their infants. In fact, the more suicidal mothers strongly perceived that they were less prepared for mothering and they expected a poorer relationship with their infants. On the PSI total score, the high suicidality group perceived overall parenting as a significantly more stressful experience and exploratory subscale analyses showed that they also viewed interactions with their infants as significantly more dysfunctional and distressing than the women lower in suicidality. Mother-infants interactions In order to answer our third research question we compared observer ratings of motherinfant interactions between the low and high suicidality groups (Table 4). Few of the mothers in either group were able to interact optimally with their infants consistently enough during either 5-minute video segment to garner the highest ratings from observers. Several significant differences were found that related to mutual regulation between the mothers and their babies. Observers rated highly suicidal mothers as significantly less able to demonstrate sensitivity and reciprocity with their infants during unstructured interactions. For example, these dyads demonstrated more problematic mutuality in that mothers were less aware Table 4 Differences in motherinfant interactions between mothers with low and high levels of suicidal thoughts during postpartum depression Discussion This study aimed to increase the knowledge of women’s suicidal ideation during the postpartum period and its’ relationship to mother-infant interactions. Specifically, we Low suicidality a (n=15) High suicidality Mean Mean Maternal Sensitivity and Reciprocity Structured Interactions 3.86 Unstructured Interactions 4.03 Parent Intrusiveness Structured Interactions 3.43 † p<0.10, * p≤0.05, ** p≤0.01 a None to Low Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 5<12 b Moderate to High Suicidality group, where scores on the PDSS suicidal thoughts subscale range from 12≤25 Unstructured Interactions Infant Positive Affect Structured Interactions Unstructured Interactions Infant Negative Emotionality Structured Interactions Unstructured Interactions Infant Initiation and Involvement Structured Interactions Unstructured Interactions Dyadic Reciprocity Structured Interactions Unstructured Interactions SD 0.56 0.47 3.54 3.56 b (n=17) t SD 0.73 0.74 1.37 2.11* 0.75 2.96 0.99 1.47 3.47 0.59 3.19 0.93 0.98 3.21 3.18 1.02 1.19 2.58 2.23 1.17 1.38 1.57 2.02* 1.59 1.81 0.69 0.85 2.12 2.46 1.23 1.20 −1.49 −1.75† 3.09 3.15 0.73 1.02 2.40 2.41 0.88 1.06 2.35* 1.93† 3.61 3.82 1.06 0.73 3.46 3.64 1.05 0.81 0.38 0.65 318 examined the prevalence of suicidality in a community sample of women with PPD who were participants in a home-based treatment. Further, we looked at differences between low and high suicidality groups on mood, perceptions of parenting, and observer ratings of maternalinfant interactions. We know of no other study that specifically addresses the relationship between mothers’ suicidal ideation and her interactions with her baby. Prevalence of suicidal ideation in this population of women with PPD was not surprising, but nevertheless important to note as pervasiveness of suicidal thoughts or actions in postpartum women has been variably reported (Lindahl et al. 2005). We saw in this sample the full range of possible scores indicating that one group of women (47%) had a few tentative thoughts of wanting to harm themselves or thinking that their babies would be better off without them (low suicidality group) and another group (53%) more strongly endorsed thoughts of wishing they could leave this earth, wanting to harm themselves, being better off dead, or feeling that death was the only way out (high suicidality group). Given these findings, special screening and attention to suicidal ideation for women who have diagnoses of postpartum depression is crucial as part of any screening program or therapeutic intervention. We expected that all of these mothers with postpartum depression would experience a range of symptoms associated with the disorder (Beck 2002; Beck and Indman 2005). However, we specifically hypothesized that those women who faced more severe symptoms in a number of domains such as mood and cognitions would experience greater suicidal thoughts. Our findings indeed showed that mothers who experienced greater severity of symptoms, including anxiety, depression, mental confusion, and guilt endorsed suicidal thoughts with greater frequency and intensity. It is possible that the experience of helplessness that often accompanies extremely depressed mood and mental confusion, and that makes caring for a dependent infant so difficult, could also lead to more suicidal thoughts. Perhaps the idea of escape in the form of suicide served as a relief given the unrelenting demands of caring for an infant coupled with the feelings of inadequacy as a mother. One might speculate that experience in mothering or having an older child would serve as protection against suicidal ideation (Adam 1990). Yet, among this group of women with PPD, veteran mothers were as depressed and suicidal as new mothers. In exploratory analyses mothers in the highly suicidal group showed more distressed and distorted thinking about loss of identity and readiness for mothering. Most of the women in this sample had held jobs before becoming mothers. The loss of a working identity in a predictable and controlled environment in which they felt competent and the shift to the unpredictability of caring for a newborn R. Paris et al. could have been enough to catapult them into severe PPD. For those professional women who garnered much of their self-esteem from workplace roles and responsibilities, taking care of a baby might have been an extremely challenging psychological task which could have catalyzed lowered self-esteem, depression, and possibly suicidality (Cramer 1993). Mothers in the high suicidality group generally experienced more distress in the parenting role than mothers in the low suicidality group. Exploratory subscale results also showed that they had lower expectations of their relationships with their infants and assessed their mother-infant interactions more negatively. While others have demonstrated the negative bond that women with postpartum depression experience with their infants (Hornstein et al. 2006), no prior studies have focused on the subgroup of mothers who strongly consider suicide. Given that the highly suicidal women also felt less prepared for motherhood, it is possible that these women had grave doubts about their abilities to parent long before they became mothers, possibly because of difficulties in the way they were parented, problems in shifting to the mothering role, or because of their own histories of depression. Interpersonal risk factors such as support from one’s spouse, and extended family and friends are also important to consider. The mutual regulatory process was more difficult for depressed mothers who experienced greater suicidal ideation. Perhaps preoccupation with suicidal thoughts as well as overall severity in depressed mood and negative self appraisal combined to remove these mothers from optimal connection with their infants more frequently than in the low suicidality group. Although not consistent across all of the maternal-infant interactions with highly suicidal women, many of the problematic ones were evident in the unstructured exchanges. Unstructured interactions may have been anxiety producing for all the mothers, but more so for those greatly troubled by suicidal thoughts. Prior research demonstrating that suicidal ideation is often associated with poor problem solving abilities (Pollock and Williams 2004) is particularly relevant for these mothers who may have had a harder time thinking “out of the box” for ways to interact with their babies, particularly when they were not given a specific task on which to structure the interaction. Overall, the depressed women who were less suicidal displayed a greater ability to acknowledge their babies in multiple ways and remain more consistently sensitive to them in unstructured interactions by staying in direct connection through their gaze. It is possible that the highly suicidal women kept a greater distance from their babies, particularly when given the opportunity in an unstructured interaction, in order to protect them from their toxic PPD, suicidality, and mother-infant interactions thoughts and feelings. These unconscious behaviors have been noted and analyzed in clinical situations (Spielman, personal communication). In structured exchanges depressed women who were highly suicidal and their babies had ratings that appeared lower, but significant differences were found only on infant initiation and involvement. It seems that the highly suicidal women were mostly similar to those low in suicidality during mother-infant interactions when a specific task was assigned and there were clear instructions. Both groups were able to respond to their infants a moderate amount of the time. Findings such as less infant involvement and positive affect, and more negative affect among the babies of highly suicidal mothers demonstrate the infants’ side of mutual regulation. It is difficult to assess causality in the motherinfant relationship as this is very early in the attachment process (Cramer 1998). Nevertheless, the findings generate questions regarding cycles of interactions. Are the babies less engaged because they’ve already “given up” having felt the greater passivity and decreased availability of their mothers? Or are the mothers’ difficulties staying consistently connected a partial response to babies who are less interactive or receptive to engagement? Limitations This study has a number of limitations. The sample was small and hence limited the types of statistical analyses we were able to compute. Our main outcomes are drawn from the total scores of relevant measures, yet selected exploratory analyses of subscales offer clearer illumination of multiple relevant domains. A larger sample size would allow for greater power to develop multivariate models, necessary to better understand the processes involved in mother-infant interactions. Additionally, the sample was comprised of educated and middle class women who had sought out treatment from a unique community program relatively early in their experiences with postpartum depression. Other women, typically those who live in poverty, find it harder to access or accept services due to cost, stigma, and cultural beliefs about mental illness and motherhood (Abrams and Dornig 2007). Approximately half of the women in the study had started on anti-depressant medications simultaneous to beginning the Early Connections program. Most reported that they were not experiencing improved mood at the pretreatment assessment. Even though this was not a treatment evaluation study, more detailed information about use of medication and the coordination of treatments could aid our understanding of types of interventions sought by women with PPD. 319 Our study was also limited by the fact that women in the sample reported suicidal ideation and not suicidal behavior. The women in the high suicidality group were clearly atrisk for suicidal actions, but none had attempted suicide. Others have studied hospitalized populations with mothers who were being treated for self-harming behaviors (Appleby and Turnbull 1995). There may be differences in mood, cognitions, and mother-infant interactions between women who have thoughts of suicide and those who actually make attempts. This study limits its findings to the former group. Clinical implications The findings from this study offer important guidance for clinical work with depressed women, whether they are low or high on suicidality, before the birth of a baby and in the postpartum year. In this sample, highly suicidal women felt significantly less prepared for their roles as mothers, anticipated more problematic relationships with their infants and experienced a greater loss of self. In addition, more than half of the women in our sample in both low and high suicidality groups had a history of depression, increasing their risk for PPD. These findings underline the importance of preparing for the changes that may ensue when one becomes a parent (Cowan et al. 1985). Anticipatory guidance regarding the physical and emotional challenges of parenting, role changes, and shifts in identity should be a necessary part of the preparation for parenthood. Findings from this study reinforce the notion that postpartum depression has a variety of presentations (Beck and Indman 2005). A measure such as the PDSS with documented specificity in screening for a range of symptoms is important to use in any at-risk population. Teasing out the depth and acuity of suicidal feelings is crucial given the risk to the mother and baby. Once women and infants are in treatment, keeping a constant awareness of suicidality in terms of thoughts, plans, triggers, and overall safety for the mother and baby is a crucial part of the psychotherapeutic process. Our findings showed that mothers in the high suicidality group had more difficulties with the unstructured tasks on the mother-infant videos. Given this finding, it is likely that interventions augmenting structure for the mother and infant could be helpful. Examples might include assisting the mother in structuring her day, identifying tasks that need to be accomplished, offering guidance in how to attune to the baby’s needs during times that the baby is awake, alerting a spouse or other family member that unstructured times are the most vulnerable for the mother and infant, and perhaps encouraging another support person to be close by in moments of high anxiety. 320 We speculated that some very depressed and highly suicidal mothers might be protecting their babies from feelings that were negative and potentially toxic by distancing themselves in interactions. If so, videotaping the mothers and infants and viewing the interactions in the context of the therapy, such as in Interaction Guidance (McDonough 2004), could help the mothers reflect on their behaviors and aid in accessing unconscious feelings that arise when the mother is relating to her baby. Ultimately, as Cramer (1998) has posited, we think our findings demonstrate that postpartum depression is a relationship disorder. Both mothers and infants are engaged in the process; mothers by being less sensitive and responsive, and infants by less involvement and positive affect and marginally more negative affect in interactions. If the disorder is based in the relationship it makes sense to treat the mother-infant dyad in order to improve the mother’s depression and suicidality as well as mother-infant interactions (Nylen et al 2006). Many authors have suggested this approach for women with PPD or other difficulties that challenge attachment processes (McDonough 2004; Slade et al. 2005; Stern 1995), but none have focused on the specific concerns of suicidal women. A hands-on dyadic treatment could be helpful for depressed and suicidal women due to the fact that improvement in mood alone does not necessarily guarantee better problem solving abilities with infants (Pollock and Williams 2004). This type of approach offers the hope of long-lasting results, as the impact of early relational difficulties is known to cause problems far into the future (Lyons-Ruth 2008). Future directions Future research with a larger sample should go deeper to understand who is at greatest risk of suicidal ideation and behavior among mothers with postpartum depression and other psychiatric conditions (e.g. Obsessive Compulsive Disorder). Studying the impact of risk factors such as history of depression as well as poverty, immigration, and family and social supports should be included. Additionally, multiple treatment approaches such as individual and dyadic psychotherapy and medications need to be further examined concurrently. As we stated above, understanding causality in the mother-infant relationship was beyond the scope of this study. Future prospective studies tracking women from pregnancy would further illuminate the transactional processes between depressed and/or suicidal mothers and infants. Findings from these types of studies would allow for further development of dyadic or family prevention and treatment approaches that address the specific triggers for suicidal ideation and the best approaches to ameliorate the difficulties for the mother and infant. R. Paris et al. Acknowledgements Support for this work was provided by the Office of the Provost at Boston University and the Faculty Grant Program at the Lois and Samuel Silberman Fund, New York Community Trust. The authors would like to thank Sally Bachman for comments on an earlier version of this manuscript, Peggy Kaufman, Eda Spielman and the staff and clients of the Early Connections Program, Greater Boston Jewish Family and Children’s Service for their time and willingness to participate in this study. References Abidin RR (1995) Parenting stress index, 3rd edn. Professional manual. Psychological Assessment Resources, Lutz FL Abrams LS, Dornig K (2007) Bridging the gap: Barriers to service use among low-income women with postpartum depression. UCLA, Department of Social Welfare, School of Public Affairs. Available via UCLA. http://www.spa.ucla.edu/sw/webfiles/ Barriers_to_Service_Use-Among_Low-Income_Women_with_ PPD_and_PPD_Toolkit.pdf. Accessed 1 Nov 2008. 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