Role functioning of Depression
DEPRESSION DURING THE perinatal period is a major public health concern. Approximately 13% of women experience postpartum depression (PPD; [O’Hara and Swain 1996]). Up to half of these women have episodes that last 7 months or longer [England et al 1994]. The most significant factor in the duration of the PPD is delay in seeking treatment [England et al 1994]. As with other cases of major depression, PPD is characterized by mood alterations, disturbed cognitive processes, and physical symptoms which result in poor role functioning at work, school, in social, family and personal relationships, and in less satisfaction in the role of mother ( [Beck 1999]; Table 1). Although most postpartum women experience a delay of 3–6 months after childbirth before they resume usual household, social, community, self-care, and occupational roles [Fishbein et al 1998, Gennaro and Fehder 2000, McVeigh 1998, McVeigh 2000, Tulman and Fawcett 1990, Tulman et al 1990 and Waters and Lee 1996], women with postpartum depression have prolonged difficulties with functioning.
Symptoms of Major Depression With Postpartum Onset
Data from the [American Psychiatric Association 1994]
Postpartum depression can be successfully treated with antidepressants [Appleby et al 1997] and/or psychotherapy [O’Hara et al 2000]. Remission of symptoms defines successful treatment of depression but current treatment goals also include return of the patient to the desired level of functioning in all of their life roles [Sederer et al 1996 and Stahl 1999].
Relationship between depression symptoms and role functioning
Although not specifically studied in women with postpartum depression, high levels of role functioning impairment have been shown in individuals with depression in both clinical [Brent et al 1998, Mauskopf et al 1996 and Wells et al 1989] and community [McKee et al 2001] samples. For example, in patients with major depression (n = 95) who were administered the Sickness Impact Profile, [Goethe and Fischer 1995] reported role functioning impairment in the areas of work, alertness, emotional behavior, social interaction, and recreation. There was only minimal impairment in ambulation, mobility and body care. The psychosocial functioning scores were most highly correlated with level of depression (r = 0.64, p < .001), similar to that reported in previous studies [Leader and Klein 1996].
Interestingly, role functioning impairment does not always parallel symptom severity. In samples of clinically depressed patients, both [Lyness et al 1993] and [Goethe and Fischer 1995] found that some individuals with mild symptoms of depression had severely impaired role functioning, whereas some individuals with severe symptoms of depression were able to function successfully in occupational and social roles. The investigators were unable to explain this perplexing finding. However, even mild symptoms of depression may impact role functioning. [Mintz et al 1992] showed that minor depression (Hamilton Rating Scale for Depression [HRSD] score < 10) was associated with loss of interest and negative self-evaluation. These scores increased dramatically with each elevation of HRSD score.
Role functioning after treatment for depression
As would be expected, role functioning impairment tends to improve with treatment as the depression remits [Coulehan et al 1997. J.L. Coulehan, H.C. Schulberg, M.R. Block, M.J. Madonia and E. Rodriguez, Treating depressed primary care patients improves their physical, mental, and social functioning. Archives of Internal Medicine 157 (1997), pp. 1113–1120. View Record in Scopus | Cited By in Scopus (126)Coulehan et al 1997]. For example, [Mintz et al 1992] used data from 10 published studies to evaluate the impact of symptoms of depression on work impairment. They found that affective work impairment (feeling of distress, shame, or lack of interest) was associated with mild depression and functional impairment (absenteeism, performance adequacy, or interpersonal conflict) was associated with more profound depression. With treatment, work improvement and symptom improvement were correlated, but work improvement took longer. It is not known how treatment of depression might impact role functioning in the postpartum period, leading to the need for the present study.
The purpose of this study was to describe any improvement in symptoms of depression and role functioning of women with PPD after 8 weeks of antidepressant treatment. A second purpose was to determine the relationship between measures of depression and role functioning of women with PPD after 8 weeks of antidepressant treatment. The study comprehensively measured numerous domains of role functioning, as well as symptoms of depression, to inform researchers and clinicians of outcomes that can be expected from antidepressant treatment.
Theoretical framework
A Stress and Coping framework [Lazarus 1999] was used to guide the study. In this theoretical framework symptoms of depression and impaired role functioning lead to increased stress. Remission of symptoms with antidepressant treatment, especially improvement in mood and increased energy, leads to the perception of decreased stress and having adequate resources to deal with challenges. The improvement in mood and energy also make use of social support more probable. This leads to improved role functioning, our definition of coping.
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