Maternal attachment insecurity is a potent predictor of depressive symptoms in the early postnatal period

Depression in the postpartum period is a common and vexing problem, affecting up to 20% of postpartum women in the U.S. (Wisner et al., 2013). It results in difficulty with infant care and other responsibilities, poor functioning within the primary relationship at a time when it is under the stress of a newborn’s arrival, and difficulty bonding with the child and establishing breastfeeding in the critical early days. There is abundant evidence for impaired infant care by depressed mothers, including undesirable practices with respect to feeding, sleep, and safety, and reduced frequency of well-child visits and vaccinations (reviewed in Field, 2010). Indeed, suicide is a leading cause of maternal death in the postpartum period (Oates and Cantwell, 2011). Furthermore, extended maternal depression may have lasting negative effects on the child’s development (see Brand and Brennan, 2009 for review). Postpartum depression (PPD) strikes at a time when caregiver responsibilities make it difficult for new mothers to attend frequent treatment sessions and attend to regular sleep and self-care responsibilities. Thus it can often go undetected and untreated for extended periods of time (Dennis and Chung-Lee, 2006). Antenatal prediction might offer women the opportunity to initiate prophylactic treatment and support; however, PPD is difficult to predict. At present, previously proposed psychosocially based predictive algorithms for PPD have been insufficiently potent for clinical utility (Austin and Lumley, 2003; Milgrom et al., 2008); and efforts to develop biologically based predictive tests for PPD (Guintivano et al., 2013; Mehta et al., 2014) and have focused solely on women with existing mood disorder histories, who constitute a minority of all women with PPD. In general, clinicians treating antenatal women have been advised to focus on history of mood disorder for risk assessment (O’Hara and Gorman, 2004). While risk for PPD is elevated in women with histories of mood disorders, in several prospective samples a majority of women with depression onset in the postpartum period had no prior history of mood disorder (Banti et al., 2011; Dietz et al., 2007). This suggests that in order to have an appreciable clinical effect, efforts to predict PPD should encompass women both with and without history of mood disorder. Premorbid personality characteristics have been hypothesized to contribute to susceptibility to PPD, and could potentially serve as clinical predictors in combination with known risk factors such as psychosocial instability and prior history of mood episodes. Several lines of investigation have examined the relationships of particular maternal personality traits to the development of PPD. One well-documented personality characteristic that has been associated with PPD is insecure attachment style (Bifulco et al., 2004; McMahon et al., 2005; Meredith and Noller, 2003; Monk et al., 2008; Simpson et al., 2003; Rholes et al., 2011). Insecure attachment is a concept first articulated by John Bowlby in his development of attachment theory (Bowlby, 1988), and insecure attachment style in adults is thought to be based to a significant degree on suboptimal experiences with early caregiving (Carlson, 1998; Sroufe, 2005; Simard et al., 2011). Subcategories of insecure attachment styles vary between measurement instruments, and include divisions such as anxious versus avoidant, ambivalent versus avoidant, and preoccupied versus fearful versus dismissing (Ravitz et al., 2010). While some authors have found greater effects on PPD of avoidant over anxious (Bifulco et al., 2004), ambivalent over avoidant (Simpson et al., 2003), or preoccupied over fearful and dismissing styles (Meredith et al., 2003), other groups have found that all insecure subtypes increase risk for PPD without significant differences between them (Monk et al., 2008; Rholes et al., 2011). Some investigators have conceptualized the transition to parenthood as a generalized life stressor that activates attachment representations (Bifulco et al., 2004; Meredith and Noller, 2003; Simpson et al., 2003). Others have hypothesized that pregnancy and childbirth specifically focus the mother’s attention on attachment concerns (Monk et al., 2008). When the activation of attachment schemas carries negative valence, as in women with pre-existing insecure attachment styles, this is associated with negative mood. We lean toward the latter interpretation, and further hypothesize that an individual’s own early experiences with caregivers lay down a schema for parenting and interpersonal attachment that is reactivated at the onset of parenthood. Women whose early experiences were suboptimal or deficient may confront lacunae in their parenting schemas that result in a crisis when faced with the responsibility of providing care of a type that they themselves did not experience, or experienced only incompletely. Dysfunctional cognitions have also been associated with PPD (Church et al., 2005; Phillips et al., 2010; Grazioli and Terry, 2000; Warner et al., 1997). These authors hypothesized that, according to cognitive theories of depression (Beck, 1967), negative cognitive schemata (both general and maternal-specific) act as a perceptual filter for external events, are represented as dysfunctional attitudes and are associated with depressed mood. A third line of inquiry has pursued the relationship of neuroticism and interpersonal sensitivity to the manifestation of PPD (Boyce et al., 1991; Boyce et al., 2001; Dennis and Boyce, 2004; Verkerk et al., 2005). This model also views these personality traits as representing increased vulnerability to external stressors (Boyce et al., 1991), producing a diathesis for depressed mood in the context of the stressor of new parenthood. Notably, there is a strong possibility that these purportedly distinct personality domains may show significant degrees of overlap in practice. However, to our knowledge there have been no attempts to assess the degree to which these distinct constructs represent independent risk factors for PPD, or to quantify the relative magnitudes of the risks they confer. Additionally, many of the studies in this area have been cross-sectional in nature, and those that are prospective in design have typically included only two or three assessment points. Because early infant development is rapid and household dynamics are often radically and repeatedly reorganized in the early months following childbirth, we wished to perform a more nuanced temporal assessment of the trajectory of maternal mood in this period. The present study was intended to explore the relative potency of antenatal measures of each of the above personality factors as predictors of depressive symptoms postpartum, with assessments at monthly intervals in the six months following delivery.