Arch Womens Ment Health (2005) 8: 221–231 DOI 10.1007/s00737-005-0097-5

Original contribution Some early indicators for depressive symptoms and bonding 2 months postpartum – a study of new mothers and fathers

M. Edhborg, A.-S. Matthiesen, W. Lundh, and A.-M. Widstro¨m

Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden

Received October 5, 2004; accepted July 17, 2005 Published online September 20, 2005 # Springer-Verlag 2005

Summary within 10 days (Sakumoto et al., 2002). The reported The aim was to investigate associations between blues, bonding, frequency varies between 20–75% (O’Hara, 1991) and perception of the child’s temperament and depressive symptoms two this mild disorder requires no treatment (Brockington, months postpartum in both parents. Questionnaires to be filled out 2004). during the first week were; Blues Questionnaires day 1–5, Postpartum Bonding Questionnaire (PBQ) and Edinburgh Postpartum Postpartum depression refers to a non-psychotic Depressive Scale (EPDS) and at two months; questions about depressive illness of moderate severity, with prevalence breastfeeding, EPDS, PBQ and the Infant Characteristic Question- and symptoms not differing from depression at other naire (ICQ). In all, 106 couples returned all questionnaires on both occasions. Although there were differences in parents’ rated levels of times of life, but with a threefold risk for onset in the blues, depressive symptoms and postpartum bonding, we found many first three months (Cooper et al., 1988; Cox et al., 1993). similarities in the ratings. Blues, bonding and depressive symptoms In general, postpartum depression disappeared within in the other partner were significantly related to EPDS in both two and six months (Cooper et al., 1988). However, parents. Thus, we found a risk for couple morbidity. The similarities between the parents’ responses could be interpreted in terms of a Beeghly et al. (2002) reported that first-time mothers broader human way of reacting to childbirth, while the differences with high levels of depressive symptoms early in the e.g. their understanding of the child could refer to different gender postpartum period continued to experience high levels roles. of distress and depressed mood throughout the first post- Keywords: Blues; maternal depressive symptoms; paternal depres- partum year. In Swedish studies the prevalence of post- sive symptoms; parental bonding and child’s temperament. partum depression varies between 7–14.5% (Wickberg & Hwang, 1996; Ba˚gedahl Strindlund & Monsen- Bo¨rjesson, 1998; Edhborg et al., 2000; Rubertsson, Introduction 2004). An increased risk of postpartum depression has While it is often considered as a positive event to been reported in women who experienced severe blues become a parent, it is well known that the birth, at least (Hapgood et al., 1988; Beck et al., 1992; Lane et al., for mothers, represents a time of great vulnerability for 1997; Fossey et al., 1997; Yamashita et al., 2000), and postpartum psychiatric disorders. A mood disorder early particularly if the women had a past history of depres- postpartum is the postpartum blues, defined as a tran- sion (Henshaw, 2003). sient depressed mood characterized by mood lability, Brockington (2004) also includes disorders found increased sensitivity, fatigue, poor concentration and within the mother-infant relationship in the concept of feelings of loneliness (Kennerly & Gath, 1987). The postpartum psychiatric disorders. He argues that the onset is usually within 1–5 days after the delivery and development of the relationship between mother and the symptoms typically last from 2–3 days and resolve infant is the most important psychological process 222 M. Edhborg et al. following childbirth and disturbances in this process year after birth. In that review the incidence of pater- could potentially pose long-term consequences for the nal depression during the first year ranged from child. ‘Bonding’ is one of the many typical words used 1.2%–25.5% in community samples (Goodman, 2004). to describe this process (Brockington, 2004). Bonding The onset of postpartum depressive symptoms in men refers to the tie between the parent and the infant, a is later when compared to women, however, their rates relationship that could be defined as unique between for depression increased during the first postpartum two people and is one that endures through time (Klaus year (Areias et al., 1996; Matthey et al., 2000). In et al., 1995). Studies in ‘‘normal’’ obstetric samples addition, studies have shown that depression in one part- have revealed that most mothers experience a surge of ner is significantly correlated with depression in the affection for the new baby very soon after birth, other (Ballard et al., 1994; Soliday et al., 1999), and followed by a sense that the baby belongs uniquely to among these men the incidence of paternal depression them. However, 15–40% of the new mothers could ranges from 24% to 50% (Lovestone & Kumar, 1993; experience a delay in the onset of affection, often due Zelkowitz & Milet, 2001). to obstetric factors such as painful labour (Robson & The a priori hypothesis of this study was that early Kumar, 1980) or psychiatric factors (Brockington, circumstances, such as previous depressive symptoms, 2004). negative life events during the last year, mode of de- The mothers’ affective mood is an important factor for livery, breastfeeding, parental blues, bonding and the a healthy mother-infant interaction (Righetti-Veltema parents’ perception of their child’s temperament might et al., 2002) and research on maternal postnatal de- predict postpartum depressive symptoms. Thus, the aim pression has consistently demonstrated negative effects was to study associations between these circumstances on the mother-infant relationship (Field et al., 1990; in the early postpartum and depressive symptoms 2 Murray, 1992; Edhborg et al., 2001) and the infants’ months postpartum. further cognitive development and behavior (Grace et al., 2003). Very few studies have discussed the relationship Method between mild depressive symptoms in the early postpar- Procedure tum, i.e. blues, and problems in the bonding process. Fleming et al. (1988) studied the emotional state of Healthy Swedish-speaking parents at the Karolinska University new mothers during puerperium and the mother-infant Hospital Maternity Clinic in Stockholm were approached in the maternity ward on the day of delivery or on the second day interaction and found no effect of depressive mood following delivery between the 18th of March and the 5th of on the maternal attachment. In contrast, Nagata et al. June (28 days), and between the 20th of August to the 5th of (2000) revealed that blues measured between day 5 November, 2002 (34 days). Parents of fatally ill children were and 10 postpartum had a simultaneous negative in- excluded from the study. The first author informed the parents fluence upon maternal attachment. A follow-up study verbally about the study and gave them written information. In showed that maternity blues were significantly related situations where only the mother was present in the ward when information was given, she was asked whether or not she to both depression and weak maternal attachment one believed that her partner wanted to participate in the study. year postpartum (Nagata et al., 2003). In accordance All mothers giving verbally informed consent were handed with this, Cramer (1993) has argued that post partum two sets of questionnaires, one for herself and one for the depression is best understood as mother-infant relational partner. The parents were asked to independently enter data disturbance. Because of the few number of studies and about their background, obstetric experience and the newborn child, and to subsequently complete questionnaires about their the inconsistent results, more information is needed mood (The Blues Questionnaire; Kennerly & Gath, 1987) on about the relationship between blues, depressive symp- each of five consecutive evenings, starting the first day after the toms and early postpartum bonding. There is also a delivery. The first 150 parents were asked to fill out the Blues need for elucidating the bonding experience for new Questionnaire for seven days as recommended by Kennerly and fathers, particularly if they experience blues or signs Gath (1987). However, when we noticed the high drop out, we of depression. tried to decrease the drop-out rate by asking the parents to fill out the Blues Questionnaire for only five days. On the seventh Depression in new fathers has been paid less attention day the parents were requested to complete questionnaires about than postpartum depression in mothers. However, in any depressive symptoms (EPDS; Cox et al., 1987) and feelings a literature review, 20 studies were located which of bonding with the newborn child (Postpartum Bonding Ques- included depressive levels in fathers during the first tionnaire; PBQ; Brockington et al., 2001). Because all mothers were discharged before the seventh day (mean length of hospital Depressive symptoms and parent-child bonding 223 stay in our study was 59.6 hours), the parents were encouraged Drop out analysis to separately complete the questionnaires at home and to return them within 14 days by mail in a pre-stamped envelope. Two The families who did not return their questionnaires within 14 months postpartum, follow-up questionnaires about depressive days postpartum were called by telephone to be reminded to symptoms (EPDS), bonds with the child (PBQ) and the child’s return the questionnaires. After one or two calls, about half of temperament (Infant Characteristic Questionnaire; ICQ; Bates these families were reached. During these telephone calls, et al., 1979) were sent to the parents. In addition, the mothers reasons for not having returned the questionnaires were sponta- were asked about breast-feeding and breastfeeding problems. neously given, such as, having the new baby was more The study was approved by the Ethics Committee at the stressful and time-consuming than they had thought it was going Karolinska University Hospital. to be, or that the mothers or the children had been ill, for instance, with mastitis or icterus, respectively, and mothers had therefore been unable to complete the questionnaires. As Participants a result of the high drop-out rate, the mothers’ drop out rate was analyzed concerning age, parity, mode of delivery and the During the study period 950 women gave birth at the clinic. child’s sex and birth weight. However, no significant differences Approximately 45% of these were not approached, due to were found for these variables between the 106 mothers who, insufficient knowledge of the Swedish language required to together with their partners, answered all questionnaires on both understand and complete the questionnaires. Four-hundred- occasions, and the other mothers who initially agreed to partic- and-sixty-five mothers and 429 fathers agreed to participate in ipate while in the maternity ward, but who eventually did not the maternity ward. After the first week postpartum, 223 (48%) return the questionnaires, fill out complete forms or participate mothers and 164 (38%) fathers returned the questionnaires. Two with their partners. months postpartum, 280 (60%) mothers and 235 (55%) fathers A second drop-out analysis was conducted, comparing the answered the second set of questionnaires. One reminder was 106 couples to the other parents in the study who had returned sent by mail if the second set of questionnaires was not returned the questionnaires with completed background data, but had within two weeks. Among those returning the questionnaires, provided insufficient information in other respects or partici- we selected only couples for this study. Intake results revealed pated without a partner. Education level, civil status, episodes that 106 couples (23% of the mothers, 25% of the fathers) had of previous depression, and the frequency of depressive symp- filled out the Blues Questionnaires all 5 days during the first toms in the mother were compared. No significant differences week, as well as the other questionnaires at both one week and were found in these variables between the two groups except two months postpartum. For an overview of the participation that the mothers’ frequency of depressive symptoms at two rate, see Fig. 1. months, but not at one week, was significantly lower in our

Fig. 1. Overview over the mothers and fathers participation rate 224 M. Edhborg et al. sample than in the group of mothers who had filled out the overview of the items). The participants are thus given an over- questionnaires incompletely or who had participated without all score, maximum 28 points, on the scale, and higher scores the partner. indicate more blues symptoms. For analyses, a total score is expressed as a percentage (in order to adjust for missing data), where the numbers of scores indicating symptoms of blues Questionnaire=Instruments related to the amount of all completed items that were calculated for each individual for each of the five days postpartum in Demographic and obstetric=child data – age, civil status, parity, accordance with Kennerly and Gath (1987). A mean percentage education, history of depression including previous postpartum score was calculated for each individual over the five days and depression, and negative life events during the last year were then overall mean percentage scores for the whole sample were answered by both parents during the first week postpartum. In calculated as recommended in Kennerly and Gath (1987) and in addition, the mothers reported obstetric data, e.g. mode of deliv- order to compare overall mean percentage scores between ery. At two months, questions about breastfeeding and breast- mothers and fathers. The scale was translated into Swedish for feeding problems were obtained from the mothers. this study. To test the quality of translation, an English-speaking The Blues Questionnaire (Kennerly & Gath, 1987) was used person retranslated it back into English. The translation was to assess the postpartum blues. This scale is the only tool devel- tested on 10 parents on the fifth day after the delivery. After oped by systematic psychometric methods to measure the blues some minor corrections, the scale was given to both parents to (Henshaw, 2003). It consists of 28 items and due to the transi- be completed for 5 days during the first week postpartum with a tory nature of the blues, it is recommended to be completed day- start on the day after the delivery. by-day during the first 7–10 days postpartum (Kennerly & The Edinburgh Postnatal Depression Scale (EPDS; Cox et al., Gath, 1987). The participant is asked to indicate how he=she 1987) was used to measure signs of depression. EPDS is a self- has been feeling that particular day for each of the 28 items by reporting scale, specifically designed to screen for postnatal checking if the feeling is present or absent. For eight items depression in community samples (Cox et al., 1987). The scale relating to positive feelings, a score of 1 is given if the emotion rates the intensity of depressive symptoms within the previous is absent that day. The other 20 items relating to negative feel- seven days. Ten items are scored on a 4-point scale, from zero to ings are scored 1 if the emotion is present (See Table 1 for an three and the total scores range from zero to thirty. Five of the items concern dysphoric mood, two concern anxiety, and the remaining items deal with guilt, suicidal ideation and an inabil- Table 1. Blues Questionnaire and subscales (Kennerly and Gath, 1989) ity to cope. EPDS has been found to have good validity for Swedish women (Lundh & Gyllang, 1991; Wickberg & Hwang, Subscales Items 1996), as similar to other validation studies (Eberhard – Gran Primary blues tearful et al., 2001). Cox et al. (1987) recommend cut-off score of (Seven items) low spirit 9=10 for screening purposes for women in the postpartum anxious period. With this cut-off, the EPDS has also been validated for over-emotional men. Matthey et al. (2001) found the EPDS both valid and tired reliable for fathers with the optimal cut-off score 9=10. The forgetful=muddle EPDS cannot confirm a diagnosis of depressive illness, but with changeable in mood aselectedcut-offscoreof9=10 for women, a sensitivity of Retardation able to concentratea a 71.4% and a specificity of 93.8% were found (Murray & (Three items) alert Carother, 1990). For men a sensitivity of 95.8% and a specificity livelya of 82.3% are calculated for the same cut-off (Matthey et al., Hypersensitivity mentally tense 2001). To be able to make comparisons between mothers and (Four items) restless fathers we chose the cut-off score of 9=10 for both mothers and over-sensitive fathers. up and down in mood a Postpartum Bonding Questionnaire (PBQ; Brockington et al., Decreased self-confidence confident 2001) was chosen to assess the parent-child relationship at one (Three items) mentally relaxeda week and at two months postpartum. The PBQ consists of 25 calma items rated on a scale of 0–5. Both positive and negative items Depression brooding on things are scored in the same direction. The sum of scores for all the 25 (Five items) irritable items is calculated for each parent and a high score indicates depressed, self-pitying more pathological responses. Brockington et al. (2001) also crying without being able to stop performed a factor analysis and four subscales were developed. The first factor was called Impaired bonding (12 items), the Despondency elateda (Three items) happya second Rejection and anger (seven items), the third Anxiety helpless about care (four items), and the last factor assessed the Risk of abuse with two items. For an overview over the subscales of Reservation emotionally reserved (Three items) social withdrawn the PBQ and its items see Table 2. The sum of scores for each emotionally numb without feelings subscale was calculated and an unfavourable parent-child rela- tionship was scored if the rating showed a score of 12 or more a Reverse scoring. on the first factor, 17 or more on the second, 10 or more on the Depressive symptoms and parent-child bonding 225

Table 2. Overview of the 25 items of the Postpartum Bonding Ques- responsiveness and activity level of the infant) and unpredict- tionnaire (PBQ) and its subscale (Brockington et al., 2001) able (five items about how easy and difficult it is to predict the infant’s needs, e.g. sleep, hunger, diapering, cuddle and holding Subscales Items and what’s bothering the baby). Impaired bonding I feel close to my babya (Twelve items) I wish the old days when I had no baby would come back Statistics The baby does not seem to be mine To compare results between mothers and fathers paired t-tests My baby winds me up were used. In addition, a series of exploratory regression I love my baby to bitsa I feel happy when my baby smiles analyses using depressive symptoms (EPDS) and postpartum and laughsa bonding (PBQ) at two months as dependent variables were My baby irritates me performed to evaluate which factors were best predicted by My baby cries to much EPDS and PBQ scores at two months. I feel trapped as a mother I resent my baby My baby is the most beautiful baby Results in worlda I wish my baby would somehow go away Background data Rejection and anger I feel distant from my baby Background data as well as data on previous de- (Seven items) I love to cuddle my babya I regret having this baby pressions, negative life events, mode of delivery and I enjoy playing with my babya breast-feeding are shown in Table 3. I feel angry with my baby My baby annoys me I feel the only solution is for someone else to look after my baby Table 3. Background data, including previous depressive mood, nega- Anxiety about care My baby makes me anxious tive life-events for mothers and fathers and mode of delivery, breast- (Four items) I am afraid for my baby feeding and breastfeeding problems in mothers are given in numbers and I feel confident when caring for my babya percentages My baby is easily comforteda Mothers N ¼ 106 Fathers N ¼ 106 Risk of abuse I have done harmful things to my baby (Two items) I feel like hurting my baby Mean age (Sd) R 32.13 (4.39), 22–44 34.18 (5.5), 24–52 Parity a Reverse coding. Primaparous 55 (52%) 55 (52%) Multiparous 51 (48%) 50 (48%) third, and 3 or more on the fourth. With this cut-off level, Marital status Brockington et al. (2001) found specificity for ‘‘normal’’ Married 60 (57%) 60 (57%) Cohabiting 46 (43%) 45 (43%) mothers between 0.85–1.00 for the four subscales. The sensitiv- ity varies between the subscales, but the subscale Impaired Education bonding seemed to identify over 90% of mothers with some University=College 62 (58%) 53 (50%) Upper secondary school 40 (38%) 44 (42%) form of bonding disorders. The scale has been translated into Compulsory school 1 4 (4%) Swedish for this study. To test the quality of translation, an Others 3 4 (4%) English-speaking person retranslated it back into English. The Previous depression scale was given to both men and women at one week and two Yes 30 (28%) 14 (13%) months postpartum. On the subscale Risk of abuse, only two mothers and four fathers scored on one of the two items Previous postpartum depression Yes 8 (7.5%) 2 included in the subscale, and was thus not calculated in the analyses. Negative life-events The Infant Characteristic Questionnaire (ICQ; Bates et al., Yes 23 (22%) 27 (26%) 1979) measured the parents’ perception of the child’s tempera- Mode of delivery ment from six months. The ICQ contains 24 items rated on a Vaginal 87 (82%) 7-point scale, with the rating of one describing an optimal com- Elective Caesarean 10 (9%) Emergency section 9 (9%) bination of temperamental traits, and seven describing a difficult temperament. Since we used the ICQ on 2-month old infants, we Breastfeeding, 2 months excluded items not relevant for infants at this age. Thus, we No 10 (9%) Yes – totally 83 (78%) shortened the scale to 18 items. These items are distributed on Yes – partial 13 (12%) three subscales, fussy-difficult (nine items, about how much and often fuss=cry, soothability, how easily upset, intensity of pro- Breastfeeding problems, 2 months Yes 56 (53%) test, the general and changeability of the baby’s mood and the No 50 (47%) overall degree of difficulty), dull (four items, about the social 226 M. Edhborg et al.

Table 4. Differences between mothers’ and fathers’ scores on the Blues Questionnaire, Edinburgh Postnatal Depression Scale (EPDS), Postpartum Bonding Questionnaire (PBQ) and the Infant Characteristic Questionnaire (ICQ). (N ¼ 104–106)

Mothers Fathers p

Blues Questionnaire overall mean percentage score 29.77 (Sd 16.57) 18.32 (Sd 10.11) <0.0001 EPDS mean score At one week 6.09 (5.05) 4.28 (2.64) 0.0002 At two month 4.38 (3.79) 2.5 (2.37) <0.0001 PBQ mean score, one week 7.51 (7.49) 7.98 (6.42) n.s. Impaired bonding 4.27 (4.11) 4.25 (3.51) n.s. Rejection and anger 1.59 (2.37) 2.15 (2.37) 0.0479 Anxiety about care 1.71 (1.77) 1.64 (1.32) n.s. PBQ mean score, two month 6.04 (5.13) 8.26 (6.8) 0.0007 Impaired bonding 3.62 (3.09) 4.32 (3.78) 0.0586 Rejection and anger 1.24 (1.78) 2.35 (2.52) <0.0001 Anxiety about care 1.17 (1.18) 1.60 (1.32) 0.0009 ICQ mean score at two month 8.84 (1.89) 9.35 (1.69) 0.0111 Difficulty 3.02 (0.82) 3.03 (0.74) n.s. Dull 3.22 (0.94) 3.27 (0.62) n.s. Unpredictable 2.61 (0.76) 3.05 (0.81) <0.0001

Comparisons between mothers and fathers Depressive symptoms measured by EPDS Parents’ mean score on the scales; Blues Questionnaire, The mean EPDS score was significantly higher in EPDS, PBQ and ICQ are shown in Table 4. mothers than in fathers both at one week and at two months (Table 4). One week postpartum, 22 mothers (21%) showed signs of depression, thus scored 10 or Blues measured by Blues Questionnaire more on the EPDS compared to 3 fathers. At two New mothers experienced more blues symptoms, i.e. months, the corresponding figures were 10 mothers had higher overall mean percentage scores on the Blues (9%) and 1 father. The mean EPDS score for mothers Questionnaire than new fathers. The mothers’ mean 6.1 was significantly higher at one week compared to 4.4 percentage score of blues for each day peaked on day at two months (p<0.0006). The corresponding figures 4 after the delivery, while fathers’ peaked on day 1 for fathers were 4.2 vs 2.5 (p<0.0001). (Fig. 2).

Post partum bonding measured by PBQ One week postpartum, no significant difference was found between the parents’ ratings on the PBQ and its subscales, except that fathers scored significantly higher on the PBQ subscale rejection and anger than did mothers. However at two months postpartum, fathers scored significantly higher on the PBQ and its subscales (Table 4). At one week, 9 mothers (8.5%) and 3 fathers scored above the recommended cut-off 12 on the PBQ subscale impaired bonding and were thus showing ‘‘mild bonding disorder’’ as classified by Brockington et al. (2001). Neither mothers nor fathers scored above the recommended cut-off on the other subscales, rejection and anger and anxiety about care. Two months postpar- tum, one mother and 6 fathers scored over the cut-off on Fig. 2. Mean percentage scores day 1–5 as measured by the Blues impaired bonding. The mothers indicated lower values Questionnaire for mothers and fathers on the total PBQ two months postpartum than at one Depressive symptoms and parent-child bonding 227

Table 5. Variables related to depressive symptoms at two months, measured by the Edinburgh Postnatal Depression Scale (EPDS) in mothers (adj. R2 ¼ 0.37) and fathers (adj. R2 ¼ 0.40)

Mothers Fathers

Coefficient Std Error t-value p-value Coefficient Std Error t-value p-value

Intercept 0.552 0.645 0.856 0.394 0.327 0.449 0.729 0.468 Previous depression 1.703 0.745 2.287 0.024 0.180 0.542 0.332 0.741 Emergency Caesarean section 2.835 1.110 2.555 0.012 0.027 0.808 0.033 0.973 Blues day 1–5 0.063 0.022 2.814 0.006 0.098 0.019 5.096 <0.0001 PBQ subscales at 1 week Impaired bonding 0.261a 0.116 2.252 0.027 0.167a 0.065 2.554 0.012 PBQ subscales at 2 months Impaired bonding 0.469 0.147 3.192 0.002 0.244 0.063 3.890 0.0002 The partners depressive mood at two months 0.253 0.138 1.828 0.071 0.163 0.052 3.152 0.002 a The negative regression coefficient on the PBQ subscale ‘‘Impaired bonding’’ at one week, but positive coefficient at two months suggests that the lowest value on the EPDS represents those having signs of impaired bonding at one week, but not at two months (if the other variables are the same). These mothers and fathers have shown ability to recover from early bonding problems, thus a sign of strength. Cases with no signs of impaired bonding at any occasion can be expected to have somewhat higher mean EPDS score at two months than those showing signs of impaired bonding at one week, but not at two months. The highest mean EPDS value can be expected in cases having signs of impaired bonding only at two months and those having signs of impaired bonding at both occasions coming in between.

week (mean 7.5 vs 6.0;p¼ 0.006), but there was no and 40% of the fathers’ variation in the EPDS scores two difference between the fathers’ PBQ scores over time. months postpartum (R2 adjusted) (Table 5). All these variables were significantly related to the EPDS at two months in the maternal model. In the paternal model Child’s temperament measured by ICQ the following independent variables were significantly Fathers perceived their children as being temperamen- related to depressive symptoms at two months; the over- tally more difficult, i.e. scored significantly higher on the all mean percentage score on the Blues Questionnaire, ICO at two months than did mothers. However, there the PBQ subscale; impaired bonding at one week and was no significant differences in the fathers’ rating on two months and the partner’s EPDS scores at two the ICQ subscales dull and fussy-difficult compared to months as seen in Table 5. mothers, but fathers rated their children significantly more unpredictable than did mothers (Table 4). Variables not included in the regression model about depressive symptoms (EPDS) Variables associated with depressive symptoms The following independent variables were not included (EPDS) two months postpartum in either of the parents’ regression model with the EPDS To be able to find out which variables influenced depres- as dependent variable and did not add much to the expla- sive symptoms, two multiple regressions were per- nation: Negative life-events (yes=no), vaginal delivery formed with the mothers’ EPDS and the fathers’ EPDS (yes=no), the two PBQ subscales, rejection and anger as dependent variables one at the time, both regressions and anxiety about care, neither at one week nor at two using different combinations of independent variables. months, breastfeeding at two months (yes=no), breast- For both mothers and fathers, the following independent feeding problems (yes=no), and the mothers’ perception variables were used in the final model: Previous depres- of the child’s temperament. sive mood (including previous postpartum depressive mood), emergency Caesarean section, the overall mean Variables associated with postpartum percentage score on the Blues Questionnaire, and the bonding (PBQ) at two months PBQ subscale; impaired bonding both at one week and two months and the partner’s EPDS scores at two To study the influences on the mothers’ and fathers’ months. These variables explained 37% of the mothers’ bonding with the child two months postpartum as mea- 228 M. Edhborg et al.

Table 6. Variables related to bonding at two months, measured as Postpartum Bonding Questionnaire (PBQ) in mothers (adj R2 ¼ 0.62) and fathers (adj R2 ¼ 0.60)

Mothers Fathers

Coefficient Std Error t-value p-value Coefficient Std Error t-value p-value

Intercept 4.130 1.528 2.702 0.0081 11.962 2.719 4.4 <0.0001 Previous depression 2.408 0.772 3.118 0.002 1.272 1.295 0.982 0.329 PBQ subscales at 1 week Impaired bonding 0.386 0.125 3.095 0.003 0.547 0.221 2.468 0.016 Rejection and anger 0.380 0.205 1.848 0.068 0.560 0.324 1.730 0.087 EPDS at 2 months 0.250 0.097 2.576 0.012 0.815 0.189 4.313 <0.0001 ICQ subscales at 2 months Fussy-difficult 1.220 0.506 2.413 0.018 0.975 0.752 1.297 0.198 Dull 0.340 0.365 0.930 0.355 2.491 0.780 3.194 0.002 Unpredictable 0.529 0.497 1.066 0.289 1.806 0.641 2.818 0.006

sured by the PBQ and subscales, two multiple regres- Discussion sions were performed with the mother’s and the father’s Discussion of the methods PBQ at two months as dependent variable one at the time. The following independent variables were used The results in this study should be interpreted with great in the final model for both mothers and fathers: previous caution since the drop-out rate was high. The early dis- depressive mood, (yes=no), the PBQ subscales, impaired charge from the maternity clinics today makes this type bonding and rejection and anger at one week, depressive of study difficult to carry out, and did not, for example, symptoms, i.e. EPDS scores at two months, and the ICQ permit us to control whether the fathers and the mothers subscales, fussy-difficult, dull and unpredictable child at filled out the questionnaires separately as they were two months. These variables explained 62% of the var- informed. The high drop-out rate might mirror the stress iation in the PBQ two months postpartum for mothers that many new parents in our society experience during and 60% of the variation in the PBQ for fathers (R2 the first postpartum period. One indicator for this sug- adjusted) (Table 6). For mothers, the following indepen- gestion is that the parents who did not return the ques- dent variables were significantly related to the PBQ at tionnaires gave stress as a reason for not answering the two months; previous depressive mood, (yes=no), the questionnaires during the reminding telephone call. PBQ subscales, impaired bonding at one week, depres- Another indication is that the drop-out rate was some- sive symptoms, i.e. EPDS scores at two months, and the what lower at two months postpartum, when the parents ICQ subscale, fussy-difficult at two months. For fathers, were likely to have become more settled with the baby the following independent variables were significantly as- than they were at one week. Thus, it might have been too sociated to the PBQ at two months; the PBQ subscales, much for the parents to fill out the relatively complicated impaired bonding at one week, depressive symptoms, questionnaires, such as the Blues Questionnaire, which i.e. EPDS scores at two months, and the ICQ subscales – should have been completed during each of the first dull and unpredictable child at two months (Table 6). consecutive five days after the delivery, particularly for those parents feeling depressed at the time. However, when comparing the 106 couples to the parents who only Variables not included in the regression returned some of the questionnaires or had a non-parti- model about postpartum bonding (PBQ) cipating partner, no differences were found regarding Negative life-events, vaginal delivery (yes=no), emer- previous depressive mood or frequency of depression gency Caesarean section (yes=no), overall mean percent at one week. But by contrast, two months postpartum score of blues, breastfeeding (yes=no), breastfeeding this sample of 106 couples showed a significantly lower problems (yes=no), the PBQ subscale, anxiety about frequency of depressed mothers (9.4%) two months the child’s care at one week, and the partner’s EPDS postpartum compared to 20.5% for the participating score at two months were not included in the regression mothers who did not return all questionnaires or had a models about the parents’ bonding to the child two non-participating partner, although they did not differ months postpartum, as measured by PBQ. significantly in the background variables. Josefsson Depressive symptoms and parent-child bonding 229 et al. (2001), using the same cut-off as we used in this toms through a more joyful interaction with the infant study, reported 13% Swedish women with signs of than fathers in families with a non-depressed mother depression at 6–8 weeks postpartum, which is closer (Edhborg et al., 2003). This indicates that non-depressed to the frequency in our study sample than the frequency fathers could diminish the negative consequences of among the dropouts. One could assume that the demand- maternal depressive symptoms for an infant. Thus, it ing design of the study might have excluded families is important for healthcare personnel to know if a with depressive symptoms at two months, but not at ‘‘depressed’’ mother has a depressed partner who might one week, and that our sample consisted of families need professional support as well, or whether the father living in a less chaotic situation than those parents is able to support the baby and the mother without out- who did not answer all questionnaires. side assistance. Blues, as measured by the Blues Questionnaire turned Discussion of the results out as a predictor for high EPDS scores at two months in both mothers and fathers. The mothers’ mean percentage Comparing the structure of the estimated regression score of blues and mean EPDS score was higher com- equations we found interesting similarities between pared to the corresponding scores for the fathers (Table mothers and fathers. In both mothers and fathers, the 4). Women’s lifetime prevalence has consistently in PBQ subscale Impaired bonding at one week showed a research been found to be about twice as high as men’s negative relation to the EPDS, but a positive relation at (Weissman et al., 1993). two months (See Table 5). A likely explanation for this The mothers’ blues symptoms peaked at day four after pattern could be that early problems in bonding are often the day of delivery, in contrast to the fathers’, which caused by circumstances surrounding the birth, while peaked day one after the day of delivery. This indicates problems appearing first at two months are more likely that blues in women is not only a general reaction that to be caused by the baby having been taken care of by a could occur after a stressor, like delivery, but instead depressed parent, not able to react to the baby’s signals. might be induced by the hormonal changes in the early If early problems are still persistent at two months, this postpartum. For fathers, it may be interpreted as an early may be caused by early circumstances, and need not reaction to the tension and tiredness related to the birth imply that the parent is depressed (see also Table 5). of the child. This explanation indicates that it could be helpful for Fathers scored significantly higher on PBQ and its caregivers to follow bonding problems over time in subscales two months postpartum than did mothers order to better understand and support parents with (Table 4), indicating that at this time the fathers had depressive symptoms. Our explanation has partly been more difficulties than mothers with the emotional rela- reported in other studies. Robson and Kumar (1980) tionship with the child. In our sample, 92% of the found that about 15–40% of new mothers experience mothers reported that they breastfed their children at transient delays in the onset of maternal affection, which two months. Although breastfeeding did not relate sig- lasted not longer than a few days or weeks at most, and nificantly to postpartum bonding in the regression equa- were caused by obstetric factors, while other studies tion for the mothers, breastfeeding is known to promote discuss the more severe bonding disturbances, which maternal bonding through Oxytocin release (Nissen are often associated with postpartum depression (Kumar, et al., 1995, Uvn€aas-Moberg, 1996) and might support 1997). mothers in emotionally regulated interaction. For both mothers and fathers, the regression equation Indeed, the fathers in our study perceived the children with the EPDS as a dependent variable contained the significantly more unpredictable than the mothers. Thus, partners EPDS as explanatory variables. Thus, we found breastfeeding might have given the new fathers a feeling a risk for couple morbidity in our sample. This finding is of being excluded from the child and they therefore supported by other studies, e.g. Matthey et al. (2000) might have found it difficult to learn about the child’s reported a significantly greater risk for fathers to score signals and needs. Instead, in the mothers’ regression the high on a depression scale at six weeks and 12 months ICQ subscale fussy-difficult was related to PBQ at two postpartum if their partners were depressed, and the months. For clinical practice, this could indicate that if a same was found for mothers. In an earlier study in mother is complaining about a fussy and difficult child, families with a mother exhibiting depressive symptoms, this should give a hint to the healthcare professional that we found that fathers in a play-situation could often there might be a bonding problem. Even though we did compensate the infant for the mother’s depressive symp- 230 M. Edhborg et al. not find a direct relation between the infants’ tempera- The Blues Questionnaire turned out to be a better ment and the EPDS it is important to bear in mind that predictor for parental depressive symptoms than the the mother might be ‘‘depressed’’ since the PBQ scale EPDS as administered on day 7 after the delivery. The was related to the EPDS at two months. Blues Questionnaire is quite complicated to apply in Previous depression in life was related to both the practice and also to interpret. Studies to develop an EPDS and the PBQ at two months in the mothers’ easier blues’ instrument are suggested for the future. regression equation. This finding indicates that the care- Until that is developed we suggest use of the EPDS, givers ought to be attentive and ask the new mothers if according to results from other studies (e.g. Dennis they had suffered depression earlier. Henshaw (2000) et al., 2004; Teissedre & Chabrol, 2004), in the early found that a past history of depression increases the risk postpartum to detect depressive mood in both mothers for postpartum depression almost three times. We did and fathers. not find a corresponding relation in the fathers’ regres- sion equation although earlier studies had found pre- vious depression in fathers to be important predictors Acknowledgements for postpartum depressive symptoms in new fathers We wish to thank the families who took part in the study. For (Goodman, 2004). financial support we thank The Centre of Caring Science, In conclusion, we found similarities between mothers Karolinska Institutet, Stockholm, General Maternity Hospital and fathers, such as symptoms of blues, impaired bond- Foundation, Stockholm and Karolinska Institutets Forsknings- ing at one and two months, and the partner’s depressive stiftelser, Stockholm. mood, which seemed to influence depressive mood at two month in both new mothers and fathers that could potentially be interpreted in terms of a broader human References way of reacting to childbirth. These kinds of reactions Areias MEG, Kumar R, Barros H, Figueiredo E (1996) Correlates are thus not gender specific. But there were also differ- of postnatal depression in mothers and fathers. Br J Psychiatry ences between mothers and fathers: such as fathers 169: 36–41. Ballard CG, Davis PC, Cullen PC, Mohan RN, Dean C (1994) scored significantly higher on the PBQ at two months Prevalence of psychiatric morbidity in mothers and fathers. Br J than mothers, and that the fathers’ scores on the ICQ Psychiatry 164: 782–788. subscales, dull and unpredictable child were signifi- Bates J, Freeland C, Lounsbury M (1979) Measurement of infant difficulties. Child Dev 50: 794–803. cantly associated to higher PBQ score at two months, Beck CT, Reynolds MA, Rutowski P (1992) Maternity blues and while mothers’ scores on the ICQ subscale Fussy-diffi- postpartum depression. J Gynecol Neonat Nurs (JOGNN) 21(4): cult was significantly associated to higher PBQ scores. 287–293. Beeghly M, Weinberg MK, Olson KL, Kernan H, Riley J, Tronick EZ Therefore, a suggestion is that mothers and fathers at (2002) Stability and change in level of maternal depressive symp- two months differed according to their understanding tomatology during the first postpartum year. J Affect Disord 71: of the child, which might be caused by practical circum- 169–180. stances and different gender roles related to a child’s Brockington I (2004) Postpartum psychiatric disorders. Lancet 363: 303–310. birth. Brockington IF, Oates J, Georg S, Turner D, Vostanis P, Sullivan M, Loh C, Murdoch C (2001) A screening Questionnaire for mother- infant bonding disorders. Arch Womens Ment Health 3: 133–140. Suggestions for clinical implications Ba˚gedahl-Strindlund M, Monsen Bo¨rjesson K (1998) Postnatal depres- sion: A hidden illness. Acta Psychiatr Scand 98: 272–275. Our results showed that caregivers should be attentive to Cooper PJ, Campbell EA, Day A, Kennerley LI, Robson KM, Bond A severe blues symptoms, signs of impaired bonding in (1988) Non-psychotic psychiatric disorder after childbirth: a pro- both mothers and fathers and should also bear in mind spective study of prevalence, incidence, course and nature. Br J Psychiatry 152: 799–806. that the father could be depressed if the mother shows Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depres- signs of depression. Previous maternal depression sion. Development of the 10-item Edinburgh postnatal depression should also be asked about. Although the fathers’ fre- scale. Br J Psychiatry 150: 782–786. quency of depressive symptoms is low, fathers might Cox JL, Murray D, Chapman G (1993) A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 163: have more trouble with the bonding process and our 27–31. results indicate that it is important to make appointments Cramer B (1993) Are postpartum depressions a mother-infant relation- with both parents 1–2 weeks after birth and to listen to ship disorder? Infant Mental Health J 14(4): 283–297. Dennis C-L (2004) Can we identify mothers at risk for postpartum how they perceive their child and experience the situa- depression in the immediate postpartum period using the Edinburgh tion at home. Postnatal Depression Scale? J Affect Disord 78: 163–169. Depressive symptoms and parent-child bonding 231

Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, Samuelsen SO Matthey S, Barnett B, Kavanagh DJ, Howie P (2001) Validation of (2001) Review of validation studies of the Edinburgh Postnatal the Edinburgh Postnatal Depression Scale for men, and com- Depression Scale. Acta Psychiatr Scand 104: 243–249. parison of item endorsement with their partners. J Affect Disord Edhborg M, Seimyr L, Lundh W, Widstro¨m A-M (2000) Fussy 64: 175–180. child – difficult parenthood? Comparisons between families with a Murray L (1992) The impact of postnatal depression on infant devel- ‘‘depressed’’ mother and non-depressed mother 2 months postpartum. opment. J Child Psychol Psychiatry 33(3): 543–561. J Reprod Infant Psychol 18(3): 225–238. Murray L, Carothers AD (1990) The validation of the Edinburgh Post- Edhborg M, Lundh W, Seimyr L, Widstro¨m A-M (2001) The long-term natal Depression Scale on a community sample. Br J Psychiatry 157: impact of postnatal depressed mood on mother-child interaction: A 288–290. preliminary study. J Reprod Infant Psychol 19(1): 61–71. Nagata M, Nagai Y, Sobajima H, Ando T, Nishide Y, Honjo S (2000) Edhborg M, Lundh W, Seimyr L, Widstro¨m A-M (2003) The parent- Maternity blues and attachment to children in mothers of fullterm child relationship in the context of maternal depressive mood. Arch normal infants. Acta Psychiatr Scand 101: 209–217. Womens Mental Health 6: 211–216. Nagata M, Nagai Y, Sobajima H, Ando T, Honjo S (2003) Depres- Field T, Healy B, Goldstein S, Guthertz M (1990) Behavior-state sion in the mother and maternal attachment – results from a matching and synchrony in mother-infant interactions of non- follow-up study at 1 year postpartum. Psychopathology 36: depressed versus depressed dyads. Dev Psychol 26(1): 7–14. 142–151. Fleming AS, Ruble DN, Flett GL, Shaul DL (1988) Postpartum Nissen E, Lilja G, Widstro¨m A-M, Uvn€aas-Moberg (1995) Elevation of adjustment in first-time mothers: Relations between mood, maternal oxytocin levels early post partum in women. Acta Obstet Scand 74: attitudes, and mother-infant interactions. Dev Psychol 24(1): 71–81. 530–533. Fossey L, Papiernik E, Bydlowski M (1997) Postpartum blues: a clinical O’Hara MW, Schlechte JA, Lewis DA, Wright EJ (1991) Prospective syndrome and predictor of postnatal depression? J PsychosomObstetr study of postpartum blues. Biologic and Psychosocial factors. Arch Gynecol 18: 17–21. Gen Psychiatry 48: 801–806. Goodman JH (2004) Paternal postpartum depression, its relationship Righetti-Veltema M, Conne-Peerreeard E, Bousquet A, Manzano J to maternal postpartum depression, and implications for family (2002) Postpartum depression and mother-infant relationship at 3 health. J Adv Nurs 45(1): 26–35. months old. J Affect Disord 70: 291–306. Grace SL, Evindar A, Stewart DE (2003) The effect of postpartum Robson KM, Kumar R (1980) Delayed onset of maternal affection after depression on child cognitive development and behavior: A review childbirth. Br J Psychitry 136: 347–353. and critical analysis of the literature. Arch Womens Mental Health 6: Rubertsson C (2004) Depression and partner violence before and 263–274. after childbirth. (Doctoral dissertation). Department of Nursing, Hapgood CC, Elkind GS, Wright JJ (1988) Maternity blues: Phenomena Karolinska Institutet, Stockholm. and relationship to later postpartum depression. Aust NZ J Psychiatry Sakumoto K, Masamoto H, Kanazawa K (2002) Post-partum maternity 22: 229–306. ‘‘blues’’ as a reflection of newborn nursing care in Japan. Int J Henshaw C (2003) Mood disturbance in the early puerperium: a review. Gynecol Obstetr 78: 25–30. Arch Womens Mental Health 6(Suppl 2): 33–42. Soliday E, McCluskey-Fawcett K, O’Brien M (1999) Postpartum affect Henshaw C, Foreman DM, Cox J (2000) Postpartum blues: a risk factor and depressive symptoms in mothers and fathers. Am J Orthopsy- for postpartum depression. Marce Society Biennial Conference. 4–6 chiatry 69(1): 30–37. September, Hulme Hall. Manchester, UK. Teisseedre F, Chabrol H (2004) Detecting women at risk for postnatal Josefsson A, Berg G, Nordin C, Sydsjo¨ G (2001) Prevalence of depression using the Edinburgh Postnatal Depression Scale at 2 to 3 depressive symptoms in late pregnancy and postpartum. Acta Obstetr days postpartum. Can J Psychiatry 49(1): 51–54. Gynecol Scand 80: 251–255. Uvn€aas-Moberg K (1996) Neuroendicrinology of the mother-child inter- Kennerley H, Gath D (1989) Maternity Blues. I. Detection and mea- action. TEM 4: 126–131. surement by questionnaire. Br J Psychiatry 155: 356–362. Weissman MM, Bland R, Joyce PR, Newman S, Wells JE, Wittchen HU Klaus MH, Kennell JH, Klaus PH (1995) Bonding. Building the (1993) Sex differences in rates of depression; cross-national perspec- foundation of secure attachment and independence. Addison-Wesley tives. J Affect Disord 29(2–3): 77–84. Publ. Reading, Ms. Wickberg B, Hwang PC (1996) The Edinburgh Postnatal Depression Kumar CR (1997) ‘‘Anybody’s child’’: severe disorders of mother-to- Scale: Validation on a Swedish community sample. Acta Psychiatr infant bonding. Br J Psychiatry 171: 175–181. Scand 1: 1–4. Lane A, Keville R, Morris M, Kinsella A, Turner M, Barry S (1997) Yamashita H, Yoshida K, Nakano H, Tashiro N (2000) Postnatal Postnatal depression and elation among mothers and their partners: depression in Japanese women . Detecting the early onset of postnatal prevalence and predictors. Br J Psychiatry 171: 550–555. depression by closely monitoring the postpartum mood. J Affect Lovestone S, Kumar R (1993) Postnatal psychiatric illness: The impact Disord 58: 145–154. on partners. Br J Psychiatry 163: 210–216. Zelkowitz P, Milet TH (2001) The course of postpartum Lundh W, Gyllang C (1993) Use of the Edinburgh Postnatal Depression psychiatric disorders in women and their partners. J Nerv Ment Scale in some Swedish child health care centres. Scand J Caring Sci 7: Dis 189(9): 575–582. 149–154. Matthey S, Barnett B, Ungerer J, Waters B (2000) Paternal and maternal Correspondence: Maigun Edhborg, Department of Nursing, depressed mood during the transition to parenthood. J Affect Disord Karolinska Institutet 23300, S – 141 83 Huddinge, Sweden; 60: 75–80. e-mail: [email protected]