Maternal Depression

Introduction

Maternal depression poses a significant burden, both to the individual and to the broader relational context.^1,2,3,4 When a mother is struggling with depression, important relationships are likely to suffer as well. Research has documented the pernicious effects of maternal depression on the marital relationship,^5,6 parenting,^7,8,9 and the mother-child relationship.^10,11,12  Furthermore, these effects are not simply limited to the period during which the mother is depressed. The long-term effects of maternal depression extend to poor child outcomes,^13,14 divorce,¹⁵ and even the perpetuation of this cycle with future generations.^16,17 Because depression is particularly prevalent during women’s childbearing years, and because it is a highly recurrent disorder, the public health significance of understanding and adequately treating maternal depression is high.

Subject

Approximately 33% of women will suffer from depression by the age of 65.¹⁸  Mothers who suffer from depression are subsequently more at risk for developing an insecure attachment with their children,^19,20,21 often engage in dysfunctional parenting,^7,8 and their children are at heightened risk for developing both internalizing and externalizing behaviour problems.^22,23  Despite these risks, it is important to note that maternal depression does not deterministically culminate in adverse outcomes for offspring and children have been shown to evidence positive development, including secure attachments to their depressed mothers.²⁴

Problems

Research on maternal depression and its effects on the family continues to face numerous challenges.

• Issues related to maternal depression and to the adaptation of offspring have not been consistently examined across investigations. However, extant research has demonstrated how certain fine-grained experiences of maternal depression (e.g., timing during offspring development,^25,26 severity²⁷) can eventuate in very different child outcomes.
• Historically, investigations focused on main effects models that sought simply to determine whether offspring were adversely affected and in what developmental domains. Examinations of processes and mechanisms contributing to outcome are less prevalent.
• The adverse outcomes associated with maternal depression are not unique to depression, raising questions as to whether it is depression per se, or rather specific aspects of parenting that contribute to negative child development.
• Far less attention has been directed to the bi-directional influences that may maintain or exacerbate maternal depression. For example, if a child has an emotional disorder or illness, then the mother’s depression may be more difficult to treat.²⁸ 
• While there are exceptions,^29,30 far too little effort has been directed to preventing the adverse effects of maternal depression on children.

Research Context

Due to the wide-ranging effects of maternal depression, research on the phenomenon must address many domains. Beyond studies of the direct effects of maternal depression on parenting, the marital relationship, and child outcomes, there have been many process- oriented studies to examine, for example, how maternal depression might affect mother-child interactions or the development of mother-infant attachment security.³¹ Recent studies of maternal depression also have addressed the interaction of children’s genotypes and environmental influences to determine potential mechanisms through which families in which the mother is suffering from depression are affected.³² In addition, intervention studies have been used to identify both effective treatments for maternal depression and its sequelae.³³ Such studies have been integral to understanding the mechanisms through which maternal depression affects other members of the family. It is important to note that an increasing number of studies of maternal depression have incorporated fathers in order to capture more fully the dynamic processes that co-occur with a mother’s depression.³⁴

Key Research Questions

Given the diversity of mechanisms and moderators that contribute to varied outcomes in children who have been exposed to maternal depression, it is increasingly important that investigations incorporate a multiple-levels-of-analysis perspective into understanding the effects of maternal depression on children.³⁵ Such an approach requires attention to psychological, neurobiological, genetic and contextual factors. Given the high degree of co-morbidity between depression and other mental disorders, increased effort needs to be directed toward understanding how co-morbidity affects children of depressed mothers. Additionally, models of intervention and assessments of their efficacy need to be developed with economically, racially, and ethnically diverse populations. Investigations that examine the complex transactions that occur across ecological systems (individual, family, school, neighbourhood) and that contribute to adaptive versus maladaptive outcomes in offspring of depressed mothers also are needed.

Recent Research Results

Increasingly, research on maternal depression has incorporated paternal influences on the effects of the disorder. Given the relative paucity of fathers in clinical research,³⁶ the inclusion of fathers provides a fuller depiction of how maternal depression can affect the family system. Meta-analytic research on psychopathology in mothers versus fathers suggests that maternal depression is more closely related to children’s internalizing, but not externalizing problems than when fathers are suffering from depression.³⁷ Furthermore, when paternal psychopathology is present, maternal depression is significantly associated with toddlers’ externalizing and internalizing behaviour problems.³⁸ In contrast, paternal involvement in infancy has been shown to moderate the relation of maternal depression and child internalizing behaviour.³⁵ More recently, paternal involvement in the family unit has been shown to moderate the association between maternal depression and family cohesion. Specifically, when fathers show greater sensitivity, low intrusiveness, and increased engagement with children, the effect of maternal depression on family cohesion appears to be dampened.³⁴

Recent research has examined the mechanisms through which maternal depression affects the family.^9,39 With regard to the fundamental infant-caregiver attachment relationship, data suggest that attachment security mediates the relation between depressive symptoms and negative parental representations.⁴⁰ In addition, maternal depression has been found to moderate the relation between attachment insecurity and the impact of home-visiting programs for at-risk mothers and infants.⁴¹

Recent studies also have demonstrated the effects maternal depression can have on child behaviour outcomes. Reductions in maternal depression resulting from intervention have led to improvements in both child externalizing and internalizing problem behaviour after accounting for the potential mediating effects of positive parenting.⁴² More recent research also has demonstrated the transactional effects of maternal depression, such that a bidirectional relationship has been identified between maternal depression and child irritability⁴³ and child oppositional behaviour,⁴⁴ with the latter relation mediated by child inhibitory control. In addition, maternal depression has been shown to affect children’s physiology.^45,46

In light of ongoing research highlighting racial and ethnic disparities in mental health challenges and access to care,^47,48 there is a subset of research on maternal depression examining patterns, effects, and treatment of maternal depression in the context of race and ethnicity. Specifically, families of color have been demonstrated to disproportionately experience discrimination,⁴⁹ racism,⁵⁰ poverty,⁵¹ more limited access to healthcare,⁵² and poor pregnancy outcomes.⁵³ However, in the context of maternal depression specifically, there have been mixed results regarding risk for depression among mothers across racial and ethnic groups. Some studies suggest that Black and Hispanic mothers are at lower risk for the experience of depression relative to their white counterparts.⁵⁴ Conversely, other empirical work has demonstrated elevated rates of depression among racial and ethnic minority mothers.^55,56,57

Research Gaps

Despite progress in recent years with respect to understanding the mechanisms and processes through which maternal depression affects children, gaps in the literature remain. In particular, theoretically guided and developmentally informed investigations that consider the complexity associated with understanding the processes through which maternal depression influences children are needed. Specifically, multiple-levels-of-analysis approaches will lead to a more complete depiction of child development in the context of maternal depression.³⁷ Utilization of molecular genetic methods, neuroimaging techniques and stress reactivity paradigms, in conjunction with psychological variables, will enhance the understanding of both heightened risk and resilience in offspring of depressed mothers. The incorporation of such an approach into the design and evaluation of preventive interventions is particularly important, as these methods will not only increase our understanding of the mechanisms through which interventions operate effectively, but also will shed light on the theory-driven models that are associated with healthy and pathological outcomes.^58,59  

Conclusions

In summary, maternal depression poses a significant burden, not only to the individual affected, but also to the family system and to society more generally. Current research on maternal depression has broadened its scope from the main effects of the disorder to how it interacts and affects the larger family system. Intervention studies demonstrate that depression in mothers can be effectively treated and that its deleterious effects on significant relationships in the family and child outcomes can be mitigated and reversed. Currently, more sophisticated research methods are being used to examine how mothers’ vulnerability to depression interacts with the broader environment, how the disorder might impact both the mothers’ and the child’s neurophysiology, and how families, and in particular children, can demonstrate resilience in the face of maternal depression. Given the stigma mothers may experience as a result of their depression and the increased likelihood of mothers being affected by the disorder, future work that addresses a mother’s sense of such stigma and her access to treatment is critical.

Implications for Parents, Services, and Policy

Research coalesces to highlight the potentially pernicious effects that maternal depression may exert not only on the individual, but also on the child, family and broader social ecology. Therefore, it is critical that the stigmatization that prevents women from being screened for and receiving mental health services when a depressive disorder is present be addressed.⁶⁰ Often depression is detected in primary care settings and, as such, it is critical that practitioners recognize and address the magnitude of the problem. When treatment is provided, all too often the broader context within which a woman resides is not considered and it is rare that outreach to other family members is provided.  Investigations have shown that treating maternal depression is not sufficient for addressing adverse effects on children.⁶¹ This is particularly troublesome because we know that effective prevention strategies are available.²⁹ Given the extensive research that has highlighted the role that parenting plays with respect to child outcome, assessments of parenting skills and the provision of interventions targeted to the child’s developmental level might be particularly effective in ameliorating the negative effects associated with maternal depression. Finally, policy advocates and insurance companies need to recognize the benefit of providing prevention to children with depressed mothers rather than waiting until a child exhibits a diagnosable mental disorder.

References

1. Goodman SH, Gotlib IH, eds. Children of depressed parents: Mechanisms of risk and implications for treatment. Washington, DC: American Psychological Association; 2002.
2. Downey G, Coyne JC. Children of depressed parents: An integrative review. Psychological Bulletin 1990;108(1):50-76.
3. Cicchetti D, Rogosch FA, Toth SL. Maternal depressive disorder and contextual risk: Contributions to the development of attachment insecurity and behavior problems in toddlerhood. Development and Psychopathology 1998;10(2):283-300.
4. Cummings ME, Davies PT. Maternal depression and child development. Journal of Child Psychology and Psychiatry 1994;35(1):71-112.
5. Hanington L, Heron J, Stein A, Ramchandani P. Parental depression and child outcomes – is marital conflict the missing link? Child: Care, Health and Development 2012;38(4):520-529.
6. Najman JM, Khatun M, Mamun A, Clavarino A, Williams GM, Scott J, O'Callaghan M, Hayatbakhsh R, Alati R. Does depression experienced by mothers leads to a decline in marital quality: a 21-year longitudinal study. Social Psychiatry and Psychiatric Epidemiology 2014;49(1): 121-132.
7. Azak S, Raeder S. Trajectories of parenting behavior and maternal depression. Infant Behavior & Development 2013;36(3):391-402.
8. Natsuaki MN, Shaw DS, Neiderhiser JM, Ganiban JM, Harold GT, Reiss D, Leve L D. Raised by depressed parents: is it an environmental risk? Clinical Child and Family Psychology Review 2014;17(4):357-367.
9. Turney K. Maternal depression and childhood health inequalities. Journal of Health and Social Behavior 2011;52(3):314-332.
10. Farmer AY & Lee SK. The effects of parenting stress, perceived mastery, and maternal depression on parent–child interaction. Journal of Social Service Research 2011;37(5):516-525.
11. Lefkovics E, Rigó J Jr, Kovács I, Talabér J, Szita B, Kecskeméti, A, Szabó L, Somogyvári Z & Baji I. Effect of maternal depression and anxiety on mother's perception of child and the protective role of social support. Journal of Reproductive and Infant Psychology 2018;36(4):434–448.
12. Slomian J, Honvo G, Emonts P, Reginster JY & Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women's Health (London, England) 2019;15:1745506519844044.
13. Bagner DM, Pettit JW, Lewinsohn PM, Seeley JR. Effect of maternal depression on child behavior: a sensitive period? Journal of the American Academy of Child and Adolescent Psychiatry 2010;49(7):699-707.
14. Kingston D, Tough S. Prenatal and postnatal maternal mental health and school-age child development: a systematic review. Maternal and Child Health Journal 2014;18(7):1728-1741.
15. Kessler RC, Walters EE, Forthofer MS. The social consequences of psychiatric disorders, III: Probability of marital stability. American Journal of Psychiatry 1998;155(8):1092-1096.
16. Garber J, Cole DA. Intergenerational transmission of depression: A launch and grow model of change across adolescence. Development and Psychopathology 2010;22(4):819-830.
17. Roubinov D, Browne D, LeWinn KZ, Lisha N, Mason WA, Bush NR. Intergenerational transmission of maternal childhood adversity and depression on children's internalizing problems. Journal of Affective Disorders 2022;308:205-212.
18. Tam J, Mezuk B, Zivin K, Meza R. US simulation of lifetime major depressive episode prevalence and recall error. American Journal of Preventive Medicine 2020;59(2):e39-e47.
19. Badovinac S, Martin J, Guérin-Marion C, O’Neill M, Pillai Riddell R, Bureau JF, Spiegel R. Associations between mother-preschooler attachment and maternal depression symptoms: A systematic review and meta-analysis. PloS One 2018;13(10):e0204374.
20. Gravener JA, Rogosch FA, Oshri A, Narayan AJ, Cicchett D, Toth SL. The relations among maternal depressive disorder, maternal expressed emotion, and toddler behavior problems and attachment. Journal of Abnormal Child Psychology 2012;40(5):803-813.
21. Śliwerski A, Kossakowska K, Jarecka K, Świtalska J, Bielawska-Batorowicz E. The effect of maternal depression on infant attachment: A systematic review. International Journal of Environmental Research and Public Health 2020;17(8):2675.
22. Goodman SH, Rouse MH, Connell AM, Broth MR, Hall CM & Heyward D. Maternal depression and child psychopathology: A meta-analytic review. Clinical Child and Family Psychology Review 2011;14(1):1-27.
23. Kingston D, Kehler H, Austin MP, Mughal MK, Wajid A, Vermeyden L, Benzies K, Brown S, Stuart S, Giallo R. Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years. PloS One 2018;13(4):e0195365.
24. Whittenburg PN, Stern JA, Brett BE, Straske MD, Cassidy J. Maternal depressive symptoms and child behavior problems: Attachment security as a protective factor. Development and Psychopathology 2023;35(2):678-688.
25. Evans J, Melotti R, Heron J, Ramchandani P, Wiles N, Murray L, Stein A. The timing of maternal depressive symptoms and child cognitive development: a longitudinal study. Journal of Child Psychology and Psychiatry, and Allied Disciplines 2012;53(6):632-640.
26. Sohr-Preston SL, Scaramella LV. Implications of timing of maternal depressive symptoms for early cognitive and language development. Clinical Child and Family Psychology Review 2006;9(1):65-83.
27. Hammen C & Brennan PA. Severity, chronicity, and timing of maternal depression and risk for adolescent offspring diagnoses in a community sample. Archives of General Psychiatry 2003;60(3):253-258.
28. Swartz HA, Frank E, Zuckoff A, Cyranowski JL, Houck PR, Cheng Y, Fleming D, Grote NK, Brent DA, Shear MK. Brief interpersonal psychotherapy for depressed mothers who children are receiving psychiatric treatment. American Journal of Psychiatry 2008;165(9):1155-1162.  
29. Beardslee WR, Wright EJ, Gladstone TR, Forbes P. Long-term effects from a randomized trial of two public health preventive interventions for parental depression. Journal of Family Psychology 2007;21(4):703-713.
30. Cicchetti D, Toth SL, Rogosch FA. Toddler–parent psychotherapy for depressed mothers and their offspring: Implications for attachment theory. In: Atkinson L, Goldberg S, eds. Attachment Issues in Psychopathology and Intervention. Mahwah, NJ: Erlbaum; 2004:229-275.
31. Duggan, AK, Berlin, LJ, Cassidy, J, Burrell, L, Tandon, SD. Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants. Journal of Consulting and Clinical Psychology 2009;77(4):788-799.
32. Araya R, Hu XZ, Heron J, Lewis G, Nutt D, Goldman D. Effects of stressful life events, maternal depression and 5-HTTLPR genotype on emotional symptoms in pre-adolescent children. American Journal of Medical Genetics Part B-Neuropsychiatric Genetics. 2009;150B(5):670-682.
33. Cicchetti D, Toth SL, Rogosch FA. The efficacy of toddler-parent psychotherapy to increase attachment security in offspring of depressed mothers. Attachment and Human Development 1999;1(1):34-66.
34. Vakrat A, Apter-Levy Y & Feldman R. Fathering moderates the effects of maternal depression on the family process. Development and Psychopathology 2018;30(1):27-38.
35. Mezulis AH, Hyde JS, Clark R. Father involvement moderates the effect of maternal depression during a child’s infancy on child behavior problems in kindergarten. Journal of Family Psychology 2004;18(4):575-588.
36. Cicchetti D, Dawson G. Editorial: Multiple levels of analysis. Development and Psychopathology 2002;14(3):417-420.
37. Phares V, Fields S, Kamboukos D, Lopez E. Still looking for poppa. American Psychologist 2005;60(7):735-736.
38. Connell A, Goodman S. The association between child internalizing and externalizing behavior problems and psychopathology in mothers versus fathers: A meta-analysis. Psychological Bulletin 2002;128(5):746-773.
39. Dietz PM, Williams SB, Callaghan WM, Bachman DJ, Whitlock EP, Hornbrook MC. Clinically identified maternal depression before, during, and after pregnancies ending in live births. American Journal of Psychiatry 2007;164(10):1515-1520.
40. Shaw DS, Connell A, Dishion TJ, Wilson MN, Gardner F. Improvements in maternal depression as a mediator of intervention effects on early childhood problem behavior. Development and Psychopathology 2009;21(2):417-439.
41. Gross HE, Shaw DS, Burwell RA, Nagin DS. Transactional processes in child disruptive behavior and maternal depression: A longitudinal study from early childhood to adolescence. Development and Psychopathology. 2009;21(1):139-156.
42. Herba CM, Glover V, Ramchandani PG, Rondon MB. Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries. The Lancet Psychiatry 2016;3(10):983-992.
43. Wiggins JL, Mitchell C, Stringaris A, Leibenluft E. Developmental trajectories of irritability and bidirectional associations with maternal depression. Journal of the American Academy of Child & Adolescent Psychiatry 2014;53(11):1191-1205.
44. Choe DE, Shaw DS, Brennan LM, Dishion TJ, Wilson MN. Inhibitory control as a mediator of bidirectional effects between early oppositional behavior and maternal depression. [published correction appears in Dev Psychopathol. 2015 Aug;27(3):943] Development and Psychopathology 2014;26(4 Pt 1):1120-1147.
45. Ulmer‐Yaniv A, Djalovski A, Priel A, Zagoory‐Sharon O, Feldman R. Maternal depression alters stress and immune biomarkers in mother and child. Depression and Anxiety 2018;35(12):1145-1157.
46. Dougherty LR, Tolep MR, Smith VC, Rose S. Early exposure to parental depression and parenting: Associations with young offspring’s stress physiology and oppositional behavior. Journal of Abnormal Child Psychology 2013;41(8):1299-1310.
47. Cook BL, Trinh NH, Li Z, Hou SSY, Progovac AM. Trends in racial-ethnic disparities in access to mental health care, 2004–2012. Psychiatric Services 2017;68(1):9-16.
48. McGuire TG, Miranda J. New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs 2008;27(2):393-403.
49. Sanders-Phillips K. Racial discrimination: A continuum of violence exposure for children of color. Clinical Child and Family Psychology Review 2009;12(2):174-195.
50. Beck AF, Edwards EM, Horbar JD, Howell EA, McCormick MC, Pursley DM. The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatric Research 2020;87(2):227-234.
51. Roschelle AR. Our lives matter: The racialized violence of poverty among homeless mothers of color. Sociological Forum 2017;32(S1):998-1017.
52. González MJ. Access to mental health services: The struggle of poverty affected urban children of color. Child and Adolescent Social Work Journal 2005;22:245-256.
53. Orr ST, Blazer DG, James SA. Racial disparities in elevated prenatal depressive symptoms among black and white women in eastern North Carolina. Annals of Epidemiology 2006;16(6):463-468.
54. Ertel KA, Rich-Edwards JW, Koenen KC. Maternal depression in the United States: Nationally representative rates and risks. Journal of Women's Health 2011;20(11):1609-1617.
55. Holloway K, Varner F. Maternal race‐related stressors and African American adolescents' academic and behavioral outcomes. Family Relations 2021;70(2):603-618.
56. Wagner KM, Valdez CR. The relationship between maternal depression, externalizing and internalizing problems in children, and caregiving burden in urban low-income ethnic and racial minority families. Child Psychiatry & Human Development 2020;51(3):390-398.
57. Gump BB, Reihman J, Stewart P, Lonky E, Darvill T, Granger DA, Matthews KA. Trajectories of maternal depressive symptoms over her child's life span: Relation to adrenocortical, cardiovascular, and emotional functioning in children. Development and Psychopathology 2009;21(1):207-225.
58. Cicchetti D, Toth SL. Developmental psychopathology and preventive intervention. In: Damon W, Lerner RM, eds. Handbook of child psychology. 6th ed. New York, NY: J. Wiley; 2006: 497-547. Siegel IE, Renninger AK, eds. Child psychology in practice. vol 4.
59. Cicchetti D, Hinshaw SP. Editorial: Prevention and intervention science: Contributions for developmental theory. Development and Psychopathology 2002;14(4):667-671.
60. Hinshaw SP. The Mark of shame: Stigma of mental illness and an agenda for change. New York, NY: Oxford University Press; 2007.
61. O’Hara M, Gorman LL. Can postpartum depression be predicted? Primary Psychiatry 2004;11(3):42-47.