Journal of Affective Disorders 107 (2008) 199–203www.elsevier.com/locate/jad

Brief report

Maternal state of mind regarding attachment predicts persistenceof postnatal depression in the preschool years

Catherine McMahon a,⁎, Tania Trapolini a, Bryanne Barnett b

a Department of Psychology, Macquarie University, North Ryde, NSW 2109, Australiab Perinatal Psychiatry, South West Sydney Area Health Service, Sydney, Australia

Received 25 April 2007; received in revised form 9 July 2007; accepted 11 July 2007Available online 16 August 2007

Abstract

Background: This prospective study aimed to determine predictors of persistent postnatal depression between child age one andfour years, in a sample of mothers already identified as having a high incidence of postnatal depression at four months after birthand a relatively high prevalence of symptoms of depression at child age one year.Methods: Data (self-report questionnaires and interview) were initially collected from 127 mothers of first-born infants recruitedfrom a parent-craft hospital at four months postpartum. Women again completed questionnaires and interviews one year after thebirth. Persistence of depression between one and four years was assessed by symptom checklists and diagnostic interview.Results: Ninety-two mothers (72%) of the original sample participated at four years. Eleven women who had first onset ofdepression after one year were excluded from analyses. Thirty-eight percent of the remaining sample (56% of those diagnosed withdepression at 4 months) reported ongoing depression between one and four years. Severity of depressive symptoms at four monthsand maternal state of mind regarding attachment (assessed at 1 year) were significant predictors of persistent depression. Womenwith an insecure state of mind regarding attachment at one year were seven times more likely to report ongoing depression.Conclusions: Findings confirm that postnatal depression is ongoing for many women and that vulnerability to persistent depressionneeds to be viewed in the context of inter-generational family problems. Severity of symptoms at four months postpartum can beused to identify those mothers most at risk of persistent depression.© 2007 Elsevier B.V. All rights reserved.

Keywords: Postnatal; Depression; Persistence; Attachment; AAI

1. Introduction

Although the majority of episodes of postnatal de-pression resolve spontaneously within the first few monthsafter birth (Cooper et al., 1991) relapse and recurrence arecommon (O’Hara, 1997) and there is a relatively highprevalence of symptoms of depression in mothers ofpreschool-aged children (McLennan et al., 2001). This

⁎ Corresponding author. Tel.: +61 2 9850 6213; fax: +61 2 9850 8062.E-mail address: cmcmahon@psy.mq.edu.au (C. McMahon).

0165-0327/$ - see front matter © 2007 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2007.07.017

paper examines factors associated with the persistence ofdepression in the preschool years in a prospective sample ofmothers, in which 60%met DSM-IV diagnostic criteria fordepression in the first four months after birth (McMahonet al., 2001) and 30% continued to report clinically elevateddepression symptoms at one year (McMahon et al., 2005).Persistence was predicted by severity of initial depressionsymptoms, low maternal care in childhood, maritaldissatisfaction, an insecure attachment style and animmature defence style reported at fourmonths (McMahonet al., 2005).Womenwith depression persisting to one year

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were more likely to have insecurely attached infants(McMahon et al., 2006), reported more negative percep-tions of their infants (Cornish et al., 2006) and their infantshad lower indices of cognitive and psychomotor develop-ment (Cornish et al., 2005).

Since children of mothers with chronic andmore severedepression typically have more adverse outcomes (Lyons-Ruth et al., 2002), this paper examines whether persistentdepression between one and four years is related to 1) thevariables which predicted persistent depression at one yearand 2) maternal state of mind regarding attachment.

2. Method

2.1. Participants

Ninety-two Australian mothers (72% of an originalsample of 127 recruited from a parent-craft centre) wereassessed at four years. Mothers not retained did notdiffer at enrolment from the remaining sample ondemographic variables or depressive symptoms. Parti-cipants had a mean age of 34.9 years (SD=4.45,range=23–48 years) and were generally highly educat-ed: university degree or professional diploma (76%,n=69), 6 years of high school (16%, n=15), and 4 yearsof high school (8%, n=8). Sixteen percent (n=15) werefrom a non-English speaking background, but mostspoke English at home. (See McMahon et al., 2001 forfull details of the original sample).

2.2. Procedure

Ethics approval was obtained from relevant institu-tional ethics committees. Mothers were interviewed andcompleted the questionnaires in their homes at fourmonths, one and four years.

2.3. Measures

2.3.1. DepressionBoth an interview (Composite International Diag-

nostic Interview: CIDI: World Health Organisation,1997) and a self-report symptom measure (CES-D:Radloff, 1977) were used at each contact to establish aninitial diagnosis and to assess episodes betweenassessments and symptom severity. Scores ≥16 on theCES-D indicate probable clinically significant levels ofdepressive symptoms.

2.3.2. Predictor variables based on four month assessmentVariables found to predict persistent symptoms at one

year (McMahon et al., 2005) were again considered:

1) the maternal care factor from the Parental BondingInstrument (PBI: Parker et al., 1979); 2) the factorAnxiety over Relationships from the Attachment StyleQuestionnaire (ASQ: Feeney et al., 1994); 3) the DyadicAdjustment Scale (DAS: Spanier, 1976) assessingmarital agreement/disagreement and 4) the immaturefactor from the Defence Style Questionnaire (DSQ:Andrews et al., 1993). See McMahon et al. (2005) forfull details of these measures.

2.3.3. Interview at 12 monthsThe Adult Attachment Interview (AAI, George et al.,

1996) administered at one year consists of 18 questionsand probes designed to elicit specific semantic andepisodic memories of childhood experiences withparents, and evaluations of the ways in which theseexperiences influence current functioning. Verbatimtranscripts were coded according to criteria specified byMain and Goldwyn (1994), and individuals assigned toone of the three major classifications: secure/autonomousif they seemed to value attachment experiences and wereable to freely evaluate the impact of these experiences ontheir later functioning, and one of two insecureclassifications, insecure/dismissing if they were activelyderogating, dismissive or idealizing about their attach-ment experiences or the impact of them, and insecure/pre-occupied if they appeared currently pre-occupied with, orlacked objectivity about their earlier attachment experi-ences. Transcripts were also coded as unresolved/disoriented if there were specific indications of mentaldisorganization or disorientation with respect to priorexperiences of abuse or loss of parents, important friendsand relatives. Certified coders blind to depression historyachieved inter-rater agreement of 86% (κ=.72, Pb.01)for the three-way coding (Dismissing, Autonomous, Pre-occupied) and 82% (κ=.67, Pb.01) for the four-waycoding (Dismissing, Autonomous, Pre-occupied, Unre-solved/disoriented). See McMahon et al. (2006) forfurther details about the reliability and validity of the AAImeasure and coding.

3. Results

3.1. Defining persistent depression

Participants were considered to have persistentdepression between one and four years if a) they metdiagnostic criteria on the CIDI at 4 months and b) metcriteria for an episode of depression between one andfour years and/or reported an elevated CES-D score(≥16) at 4 years (N=31; 38%). Eleven mothers whoreported a first episode of depression between one and

Table 1Logistic regression predicting persistent depression between 1 and 4 years

Wald df Significance Exp(B)

95.0% C.I. forEXP(B)

Lower Upper

Step 1AAI — secure vs.

insecure6.20 1 .01 9.19 1.60 52.68

Anxiety aboutrelationships

.02 1 .88 .98 .81 1.19

CES-D 12 mths 3.35 1 .07 1.11 .99 1.24CES-D 4 mths 4.49 1 .03 1.16 1.01 1.33Immature factor

(DSQ)1.35 1 .25 .97 .92 1.02

Maternal care (PBI) .02 1 .89 1.01 .89 1.14Marital satisfaction 1.16 1 .28 .97 .91 1.03

Final modelAAI — secure vs.

insecure5.53 1 .02 6.78 1.38 33.47

CES-D 12 mths 2.88 1 .09 1.08 .99 1.18CES-D 4 mths 5.38 1 .02 1.14 1.02 1.28

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four years were excluded. Eighteen women (58%) werecurrently taking or had taken antidepressant medication.Women with persistent depression did not differ fromthose who had recovered on demographic variables, butwere significantly more likely to be separated from theirpartners: χ2 (1, N=82)=10.56, P=.002; 2% (n=1) ofrecovered women vs. 25% (n=8) of women with per-sistent depression. Fig. 1 shows that women withpersistent depression reported significantly highersymptoms of depression at each contact in the study.

3.2. AAI classifications

Forty-four percent (n=37) were classified as secureand 56% (n=45) insecure. The insecure group com-prised 23 women (28%) classified as dismissing and 22women (27%) classified pre-occupied. All 17 women(21%) classified unresolved/disoriented, were alsoclassified as insecure. At four years, 78% of thosewith persistent depression had been classified insecureat one year compared with 42% of recovered women, χ2

(1, N=82)=10.34, P=.001.

3.3. Prediction of persistent depression

Logistic regression with backwards eliminationincluding the four month predictors, AAI Classificationand depression symptoms at one year indicated thatdepression symptoms at four months and AAI classifi-cation were the only two significant independentpredictors of persistent depression at four years, Waldχ2 (1)=5.38, P=.02, OR=1.14; Wald χ2 (1)=5.53,P= .02; OR=6.78), respectively, see Table 1.

A posthoc analysis examining the insecure subcate-gories showed both were comparable in predictingpersistent depression, (secure vs. dismissing: Wald χ2

Fig. 1. Mean CES-D scores for mothers with persistent depression andrecovered mothers. Note: a. Scores ≥16 are considered clinicallysignificant. b. Differences between means at each time-point aresignificant at Pb.001.

(1)=6.47; P=.01, OR=4.52; secure vs. pre-occupied:Wald χ2 (1)=7.13; P=.01, OR=4.97.

4. Discussion

More than half the women diagnosed with postnataldepression continued to experience episodes of depres-sion beyond the first postnatal year. Both severity ofsymptoms at four months and an insecure state of mindregarding attachment were independent predictors ofpersistent depression. Findings complement a body ofresearch linking adverse caretaking in childhood withvulnerability to depression in adulthood (see Gladstoneand Parker, 2005 for a review), and to postnataldepression more specifically (e.g., Boyce et al., 1991;Matthey et al., 2000). Further, there is evidence using adifferent interview measure that an insecure attachmentstyle is associated with antenatal depression and the onsetof postnatal depression (Bifulco et al., 2004). Moreover, aprior experience of childhood adversity, interpersonaldifficulties and cognitive factors have emerged across arange of studies as factors likely tomake individuals morevulnerable to a chronic course of depression in adulthood(see Lara and Klein, 1999 for a review).

Current findings extend this body of research, however,in a number of ways. The AAI provides several advantagesover other approaches. Designed to access unconsciousstructures (Maier et al., 2004; Main, 1996), the measure isrobust to both positive and negative reporting biases, as thecoding strategy involves a detailed analysis of coherence

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and emotional flexibility, rather than the content of theresponse (Main, 1996). An important advantage is thecapacity to identify distortions and emotional defences suchas idealizing responses. The measure also distinguishesbetween adverse childhood experiences and current state ofmind, as respondents who have had adverse caretaking inchildhood may be classified (earned) secure if their currentstate of mind regarding these experiences is judged to beobjective, flexible and coherent.

Attachment theory (Bowlby, 1973) provides anintegrative developmental framework that proposesthat early care-giving experiences are represented asrelatively stable internal working models of relation-ships, which influence subsequent models of self andothers, relationship functioning and negative moodregulation. Thus, secure–autonomous adults demon-strate relatively undefended integration of their earlierattachment experiences, allowing them to functionflexibly in goal-corrected partnerships with others thatcontribute to a sense of safety and wellbeing (George andWest, 1999). Insecure states of mind regarding attach-ment, on the other hand, incorporate relatively stabledefensive strategies for processing attachment-relatedthoughts and feelings acquired during childhood andmaladaptive working models of self and others that maycontinue to compromise adult capacity to draw effec-tively on both internal and external resources in times ofstress (Carlson et al., 2003).

With regard to internal resources, there is recentevidence that secure state of mind regarding attachment isassociated with more flexible thinking about emotion(DeOliveira et al. 2005) and researchers have linkedinsecure attachment styles with emotion-focused copingstrategies in response to both laboratory stressors(Mikulincer and Florian 1998) and stresses during earlyparenthood (Alexander et al., 2001).

Problematic interpersonal relationships may promoteand maintain depression (e.g., Brown and Harris, 1978).Central to attachment theory is the propensity of secureindividuals to seek support from others in regulatingtheir negative affect in times of stress. It was noteworthythat women with an insecure state of mind regardingattachment were more likely to be divorced or separatedsuggesting limited intimate support. An insecure state ofmind may also contribute to the relatively high rate ofnon-compliance with intervention strategies reported inwomen with postnatal depression (Pope, 2000). Inparticular, dismissing adults may be more difficult toengage and less likely to respond to psycho-dynamicallyoriented interventions (Dozier et al., 1999).

Recruitment from a parent-craft hospital limitsgeneralisability of the findings. In addition, the small

sample meant variability regarding duration, timing andnumber of episodes of depression was not consideredand a meaningful analysis of treatment effects was notpossible. Despite these limitations, findings confirm thatattachment histories and patterns constitute a usefulaetiological framework with which to approach mentaldistress (Schwartz and Pollard, 2004) and suggest thattreatment needs to incorporate a psychodynamiccomponent, promote supportive relationships in boththe personal and professional context, challenge mal-adaptive working models of self and others andrecognize that a core aspect of change is the achieve-ment of an increase in mentalising ability or reflectivefunctioning (Fonagy et al., 1996). Attachment theoryalso informs treatment as different attachment stylesmay require different approaches and different thera-peutic tasks (Dozier et al., 1999; Fonagy et al., 1996).

Finally, it needs to be acknowledged that from apractical standpoint the AAI, a complex, time-consum-ing, and costly procedure, is not feasible as a screeninginstrument. Current findings suggest, however that earlysymptom severity may be a reliable and cost-effectiveway to identify those women vulnerable to longer-termand more severe problems.

Role the funding sourceThe funding source, Financial Markets Foundation for Children

played no part in the study design, data analysis or write-up.

Conflict of interestThe authors have no conflicts of interest.

Acknowledgements

This research was supported by a grant from theFinancial Markets Foundation for Children, SydneyAustralia. Thanks to the mothers for continuing to givetheir time to this research, to Sue Watson for coding theAdult Attachment Interview transcripts and to AlanTaylor for statistical advice.

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