Mothers with postpartum depression with suicidal thoughts and their infant interactions

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Those are the findings of a new two-year study by Ruth Paris, Ph.D., Assistant Professor of Clinical Practice at Boston University's School of Social Work, Rendelle E. Bolton, a graduate student at the BU School of Social Work and M. Katherine Weinberg, Ph.D., a psychologist and an infant development specialist. Their research "Postpartum Depression, Suicidality and Mother-Infant Interactions appears in the September 3rd online edition of Archives of Women's Mental Health. Postpartum depression, they note, occurs in an estimated 19 percent of new mothers and ideas of suicide is considered a common part of this serious mental health problem.

The team worked with clinicians at the Jewish Family and Children's Service Early Connections program, a home-based mother-infant psychotherapy intervention that specializes in the treatment of postpartum depression (PPD) and mood disorders. The program's key goal is to increase the mother's ability to be affectively present in her interaction with the child and to address issues that arise as result of becoming a mother.

The participating women -- most of them first-time mothers in their 30s - had a wide range of suicidal thinking, as the study examined the phenomenon of suicidality and its relationship to maternal mood, perceptions and mother-infant interactions.

All the new mothers in the study suffered from depression, isolation and extreme difficulties in parenting infants. They responded to a series of pre-treatment questionnaires, self-report symptom inventories and parenting stress indices. Each of the 32 participants was also observed and videotaped twice - the first to evaluate a structured task-oriented (asking the parent to guide the infant in following a rattle) and later an unstructured interaction (how they interacted with their baby without the use any toys or other props).

To evaluate the clinical levels of the new mothers' maternal mood and psychological functioning, the women were each given the Post Partum Depression Screening Scale that assessed their postpartum psychiatric difficulties. It also included a suicidal thoughts subscale that assessed the degree to which the mother felt her baby would be better off without her, wished she leave this earth, wanted to harm herself, felt that death was the only way out and thought she would be better off dead.

Seventeen of the 32 participants (53 percent) comprised the high suicidality group and the study found that those women were experiencing more sleeping and eating problems along with greater severity in overall struggles attributable to postpartum depression.

"These mothers- were also feeling more anxious, emotionally labile, mentally confused, had experienced a greater loss of self and felt greater guilt about their experience," the study states.

Examining maternal perceptions, the researchers found that mothers with suicidal ideas had poorer self esteem than women who had few suicidal thoughts and experienced less distress in the parenting role. The high suicidality group also perceived they were less prepared for mothering and expected a poor relationship with their infants. Observers also found these women "less able to demonstrate sensitivity and reciprocity with their infants during unstructured interactions-[they] were less aware of their babies' social signals and showed poorer ability to respond to them consistently."

In turn, the infants of the more suicide-prone mothers exhibited less positive behavior in the form of fewer smiles and more fussing. "Infants of highly suicidal mothers were somewhat more passive and less engaged in the interactions," the study notes.

Researchers also found that most of the women in the highly suicidal group held jobs before becoming mothers - a significant life changing experience where they left behind their working identity in a predictable and controlled environment where they felt competent, to the unpredictability of caring for a newborn. This dramatic change could have been enough to catapult them into severe post partum depression.

"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 mother role or because of their own histories of depression.," the study states, adding that spouse and extended family support are also important to consider.

For mothers with suicidal ideas, their difficulties in unstructured tasks call for interventions that would augment the structure for their interactions with their child. Examples include the mother structuring her day, identifying tasks that need to be accomplished, offering guidance in how to attune to the baby's needs when the baby is awake, alerting a spouse or other family member to step in when she is most vulnerable and gaining support from a person close by in moments of high anxiety.

"For these depressed women with suicidal ideas, they may have prepared for the birth of their babies in some ways, but there was a paucity of emotional preparation and anticipation of some of the difficulties ahead, particularly regarding how they and their partners lives would change," said Paris. "The treatment of PPD should include the mother with the infant -- not the mother alone -- to best remediate the relationship where depressed mothers are often less able to be sensitive and responsive to their babies."

Boston University Medical Center