www.elsevier.com/locate/jad

Journal of Affective Disor

Research report

Psychological factors associated with persistent postnatal

depression: past and current relationships, defence styles

and the mediating role of insecure attachment style

Catherine McMahona,*, Bryanne Barnettb, Nicholas Kowalenkoc, Christopher Tennantd

aPsychology Department, Macquarie University, North Ryde 2109, NSW, AustraliabPerinatal Psychiatry, South Western Sydney Area Health Service, Liverpool 2170, Australia

cDepartment of Child and Adolescent Psychiatry, Royal North Shore Hospital, St Leonards 2067, AustraliadDepartment of Psychological Medicine, University of Sydney Northern Clinical School, St Leonards 2067, Australia

Received 17 December 2003; received in revised form 13 May 2004; accepted 20 May 2004

Abstract

Background: This study prospectively investigated the factors underlying the maintenance and persistence of postnatal

depression beyond the first year after birth.

Method: One hundred primiparous women who were admitted to a parentcraft hospital for a week were assessed after discharge

at 4 and 12 months postpartum. Various measures of mood, interpersonal relationships and defence styles were administered at

4 months and the relation between these measures and clinically elevated symptoms of depression at 12 months was examined.

Results: At 12 months, 30% of all mothers and 60% of those diagnosed depressed at 4 months continued to report clinically

significant levels of depressive symptomatology. The strongest predictor of depression at 12 months was severity of symptoms

at 4 months, and women from a non-English speaking background were significantly more likely to remain depressed. Reports

of low maternal care in childhood, marital dissatisfaction at 4 months, an attachment style characterised by anxiety over

relationships and immature defence styles were significant predictors of clinically elevated depression scale scores at 12

months. Furthermore, an insecure attachment style was shown to mediate the effect of low maternal care in childhood, while

other cognitive and interpersonal factors appeared to contribute additively in maintaining depressive symptoms.

Limitations: Self-report measures were used to measure insecure attachment styles and depression at 12 months.

Conclusions: Findings demonstrate that both childhood and concurrent relationship difficulties contribute to the maintenance of

postpartum depression. Interventions for persistent depression need to address relationship difficulties as well as depressive

symptomatology.

D 2004 Elsevier B.V. All rights reserved.

Keywords: Postnatal depression; Persistence; Risk factors; Attachment style; Defence style

0165-0327/$ - s

doi:10.1016/j.jad

* Correspon

ders 84 (2005) 15–24

ee front matter D 2004 Elsevier B.V. All rights reserved.

.2004.05.005

ding author.

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–2416

1. Introduction

Although the majority of depressive episodes after

childbirth resolve spontaneously within 3–6 months

(Cooper et al., 1991), a subset of women remain

depressed throughout and beyond the first postnatal

year. Studies have reported that approximately 20–

25% of mothers of toddlers (Campbell and Cohn,

1997; McLennan et al., 2001), 13% of mothers of 2-

year-olds (Campbell and Cohn, 1997) and 17% of

mothers of 3-year-olds (McLennan et al., 2001) report

clinically elevated symptoms of depression, with 36%

of those with elevated scores at 18 months also

showing elevated scores at 3 years (McLennan et al.,

2001). Furthermore, studies of women undergoing

treatment for postnatal depression have reported

relapse/recurrence in approximately 50% of cases

(O’Hara, 2002).

1.1. Chronic postnatal depression and child outcomes

Persistence of depressive symptoms throughout and

beyond the first postnatal year is of particular concern

given recent findings that children of mothers with

postnatal depression are most likely to experience

problems with development when the maternal depres-

sion is chronic and/or severe (Campbell and Cohn,

1997; Field, 1992; Kurstjens and Wolke, 2001;

Brennan et al., 2000). More attention needs to be

directed to understanding the role of co-occurring risk

factors, which may contribute both to onset and

maintenance of maternal depression and to the adverse

child outcomes (Downey and Coyne, 1990; Cicchetti et

al., 1998). This is the focus of the current paper.

1.2. Predictors of chronicity

While a considerable body of research has examined

predictors of onset of postnatal depression (see Beck,

2001 for a meta-analysis), fewer studies have explored

prospectively which risk factors are associated with

persistence of depressive symptoms. Prior experience

of childhood adversity, interpersonal factors (negative

behaviours which may elicit negative responses from

the social environment) and cognitive factors (how the

individual processes and responds to symptoms) have

emerged across a range of studies as factors likely to

make individuals more vulnerable to a chronic course

of depression in adulthood (Lara andKlein, 1999). Lara

and Klein noted the need for prospective studies to

determine whether dysfunctional cognitive styles and/

or interpersonal difficulties mediate the effects of

adverse childhood experiences or whether they jointly

contribute to depression chronicity. The primary aim of

the research reported here was to explore the role of

adverse childhood experiences, and the possible

mediating role of interpersonal difficulties and dys-

functional cognitive and coping styles in the persis-

tence of postnatal depression.

1.2.1. Adverse childhood experiences

Harsh parenting (characterised by low care and

high control) is known to predict vulnerability to

depression in adulthood (e.g., Parker, 1983; Bifulco et

al., 1994), symptom severity (Enns et al., 2000) and

failure to recover from a major depressive episode

(Brown et al., 1994). With respect to postnatal

depression, low parental care and parental over-

protection during childhood have been identified as

predictors of onset in a number of prospective studies

across the transition to parenthood (Boyce et al.,

1991; Crockenberg and Leerkes, 2003; Gotlib et al.,

1991; Matthey et al., 2000). Interestingly, findings

from two of these studies that also examined the

course of postnatal depression (Boyce et al., 1991;

Matthey et al., 2000) suggest that different risk factors

may be implicated in onset and persistence of

depression. Specifically, prior experience of dysfunc-

tional parenting may be important in the early months

of parenting, while current relationship variables

(specifically marital satisfaction) may be more impor-

tant later in the first postnatal year.

Recently, researchers have suggested that the effect

of negative childhood experiences on adult vulner-

ability to depression may be mediated through an

insecure attachment style and associated individual

differences in capacity for affect regulation (West et

al., 1999). Insecure attachment styles have been

shown to be strongly associated with severity of

depressive symptomatology (West et al., 1999) and

with more intense negative emotion (Feeney, 1999) in

adult women. To date only one study has specifically

explored the role attachment styles may play in the

onset of postnatal depression. In a prospective study,

Bifulco et al. (2004) have demonstrated that insecure

avoidant attachment styles were associated with

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–24 17

antenatal depressive disorder, while insecure

enmeshed styles were associated with postnatal

disorder. Insecure attachment styles may contribute

to personality vulnerabilities in adulthood and to

concurrent interpersonal difficulties, leading to lower

levels of social support. The current study aims to

explore whether insecure attachment styles contribute

to the persistence of postnatal depression.

1.2.2. Interpersonal difficulties

A cluster of personality vulnerabilities including a

tendency to self-criticism (Priel and Besser, 1999),

low self-esteem (Fontaine and Jones, 1997) and

interpersonal sensitivity (Boyce et al., 1991; Matthey

et al., 2000) have been identified in prospective

studies as predictors of onset of postnatal depression.

Problematic marital relationships antenatally have

also been shown to predict onset (Boyce et al.,

1991; Gotlib et al., 1991; Matthey et al., 2000) and

Boyce et al. (1991) suggest that a dysfunctional

marriage and high interpersonal sensitivity may

interact to determine ongoing morbidity.

1.2.3. Maladaptive defence styles and coping

strategies

Studies exploring maladaptive coping strategies as

risk factors for postnatal depression have yielded

mixed findings. Two studies (Demyttenaere et al.,

1995; Terry et al., 1996) have found that emotion-

focused coping strategies predicted depressive symp-

toms at 6 months postpartum, but a study by Da Costa

et al. (2000) found that emotion-focused coping was

not a significant predictor of postpartum depressed

mood.

One possibly fruitful area of enquiry is the role of

immature defence styles in the persistence of depres-

sion (Bloch et al., 1993). Although a few cross-

sectional studies have demonstrated a strong associ-

ation between immature ego defences and depressive/

affective disorders (e.g., Spinhoven and Kooiman,

1997; Bloch et al., 1993), longitudinal designs are

required to clarify whether immature defence styles

predispose adults to depression or whether depressed

mood leads to the use of immature defences (Spin-

hoven and Kooiman, 1997).

The present study aimed to replicate and extend

previous research in several ways. A primary objec-

tive was to explore the predictors of persistence of

postnatal depression at 12 months. In keeping with

findings of earlier studies, the role of adverse child-

hood experiences was examined. In order to facilitate

a greater understanding of the processes which

maintain postnatal depression, a second objective

was to explore the possibility that current inter-

personal difficulties (marital satisfaction, an insecure

attachment style), and/or maladaptive coping styles

(immature defences) might mediate the relationship

between adverse childhood experiences and depres-

sive symptoms at 12 months postpartum.

2. Method

2.1. Design of the study

The data for this research were collected as part of

a larger longitudinal study of postnatal depression and

infant development. A consecutive sample of mothers

admitted to a publicly funded parentcraft centre for a

1-week program of support with infant difficulties

such as feeding, settling and sleeping were invited to

participate in a longitudinal study of postnatal

depression and child development. The sample was

recruited when infants were 2–4 months old. Mothers

were interviewed in their homes at 4 and 12 months

and on both occasions completed a range of self-

report questionnaires.

2.2. Participants

The criteria for entry were that the mothers were

primiparous, had a singleton child, were living with

the child’s father at the time of recruitment, and were

able to complete the questionnaires and interviews in

English. Ninety percent of the 141 eligible mothers

agreed to participate in the study, giving an initial

sample of 127 mothers. Retention of participants

across the two assessment periods was very high:

114 mothers (90%) and their infants (58 male, 56

female) maintaining involvement in the study at 12

months. Ten mothers were lost to follow up because

they had moved house and could not be located,

while a further three withdrew due to illness of the

infant or another family member. Only those mothers

who completed all questionnaires at both four and 12

months have been included in the current report

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–2418

(n=100, 79% of the original sample). The mean age

of mothers was 31.42 years (S.D.=4.24, range 22–

44). The sample was highly educated compared with

the general postpartum population in Australia with a

majority of mothers (72%, n=72) reporting tertiary

level education (50% university and 22% technical

colleges); 20 mothers (20%) had been raised in a

family in which a language other than English

(predominantly European languages) had been spo-

ken (NESB). Maternal education and NESB were

controlled in all analyses. Data collected at the 4-

month assessment indicated that the mothers who

were not retained in the study and those who were

not included in analyses due to missing questionnaire

data did not differ from the remaining sample on

depression status, education or on the number of

languages spoken at home (PN0.10). Those lost to

follow-up tended to be younger than those retained

(P=0.06).

2.3. Measures

2.3.1. Depression

Mothers were interviewed at the 4-month assess-

ment using the depression module of The Composite

International Diagnostic Interview (CIDI, World

Health Organisation, 1997) to establish whether they

met diagnostic criteria (DSM-IV) for an episode of

major depression during the time period since the

baby had been born. Mothers’ depressive symptoma-

tology was also assessed at both 4 and 12 months

using the Centre for Epidemiological Studies Depres-

sion Scale (CES-D; Radloff, 1977). This widely used

scale is a 20-item self-report measure of the frequency

of depressive symptomatology over the previous

week. Total scores of 16 or more indicate probable

clinically significant levels of depressive symptoma-

tology (Radloff, 1977). In the current study, if women

had CES-D scores N16 at the 12-month assessment,

they were considered to have persistent depression.

This cut-off score has been widely used in North

American samples to indicate clinically significant

depression in the early years after childbirth (e.g.,

Campbell and Cohn, 1997; Field, 1992).

2.3.2. Risk factors

The mother’s evaluation of her early relationship

with her own parents was assessed using the Parental

Bonding Instrument (PBI) (Parker et al., 1979). The

PBI consists of two 25-item questionnaires that

measure adults’ perceptions of how their mothers

and fathers behaved towards them in childhood,

yielding two dimensions (Care and Protection). The

measure has been shown to have high reliability,

stability over time and no association with social

desirability, neuroticism or extroversion. The resist-

ance of the instrument to contamination by mood state

has also been demonstrated (Parker, 1981).

Marital satisfaction was assessed using the Dyadic

Adjustment Scale (DAS) (Spanier, 1976), a 32-item

questionnaire that assesses the extent of agreement or

disagreement between partners on a range of issues.

The 32 items can be grouped into four meaningful

factors: dyadic satisfaction, dyadic cohesion, dyadic

consensus and affectional expression, which are

conceptually and empirically related to dyadic adjust-

ment. Content, criterion-related and construct validity,

and high internal reliability (Cronbach’s a=0.96) havebeen demonstrated.

Attachment style was measured using the Attach-

ment Style Questionnaire (ASQ) (Feeney et al., 1994),

a 40-item questionnaire which has been validated by

demonstrating patterns of association with other self-

report attachment measures, measures of family

functioning and measures of personality. Two sub-

scales (13 items) were used to provide measures of the

two principal constructs underlying insecure attach-

ment: bdiscomfort with closenessQ and banxiety over

relationshipsQ. Sample items for the bdiscomfort with

closenessQ scale include (bI find it difficult to depend

on othersQ and bWhile I want to get close to others, I

feel uneasy about itQ). Sample items from the banxietyover relationships scaleQ include bI worry a lot about

my relationshipsQ and bI worry that others don’t care

about me as much as I care about themQ).Maladaptive cognitive styles were assessed using

the 40-item version of the Defence Style Questionnaire

(DSQ) (Andrews et al., 1993), which assesses the

defence strategies used by individuals to cope with

stressful situations or events. Items are rated on a nine-

point scale and measure the tendency of individuals to

endorse specific defences. The questionnaire yields 3

factors computed by taking the mean of items assessing

4 mature, 3 neurotic and 10 immature defences,

respectively. Examples of mature defences include

humour, anticipation, sublimation and suppression;

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–24 19

neurotic-idealization, reaction-formation, undoing and

immature–passive–aggressive, projection, acting out,

denial, somatization and rationalization.

Table 1

Means and standard deviations for psychosocial risk factorsa at 4

months according to diagnosis of depression based on clinica

interview (CIDI)

Mean (S.D.) Mean (S.D.)

Depressed since

childbirth (n=62)

Not depressed

since childbirth

(n=38)

CES-D symptom

score (4 months)**

5.96 (4.06) 14.56 (9.58)

Parental bonding (PBI)

Maternal care 23.12 (7.73) 25.42 (5.21)

Maternal protection 13.19 (7.15) 11.25 (6.83)

Paternal care** 21.85 (8.00) 26.48 (6.12)

Paternal protection 17.06 (6.71) 15.79 (4.16)

Attachment styles (ASQ)

Discomfort with closeness** 34.75 (5.50) 29.10 (6.73)

Anxiety over relationships* 26.17 (6.62) 23.21 (5.06)

Defence styles (DSQ)

Immature** 86.87 (19.84) 76.59 (17.08)

Mature** 42.11 (8.14) 46.78 (5.81)

Neurotic 38.50 (9.14) 37.72 (7.09)

Marital satisfaction** 111.73 (14.54) 120.16 (12.45)

a With the exception of marital satisfaction, higher scores are

more problematic.* Pb0.05.** Pb0.01.

3. Results

3.1. Prevalence of postpartum depressed mood

Of the 100 women, 62% met diagnostic criteria for

a major depressive episode in the 4 months since the

baby had been born. The mean score on the CES-D

was 11.71 (S.D.=8.91, range=0–46) at 4 months and

12.12 (S.D.=9.99, range=0–48) at 12 months. The

correlation between CES-D scores at 4 and 12 months

was 0.524 (P=0.000). At both 4 and 12 months, 30%

of mothers scored above the clinical cut-off (N16).

Sixty percent of mothers who scored 16 or more on

the CES-D symptom measure at 4 months also scored

above 16 on the CES-D at 12 months.

3.2. Relations between demographic variables, diag-

nosis of depression and CES-D scores

Mothers who were not tertiary educated were

more likely to be diagnosed through clinical inter-

view as depressed at 4 months, v2(1)=6.45, P=0.01,but not significantly more likely to report elevated

symptom scores on the CES-D at 12 months,

v2(1)=3.79, P=0.08. Although proportionally more

mothers from a non-English speaking background

were diagnosed as depressed (75% vs. 60%), this

difference was not significant. At 12 months,

however, women from a non-English speaking

background were more likely to report elevated

symptoms of depression on the CES-D, v2(1)=4.92,

P=0.03. Maternal education and non-English speak-

ing background were controlled in all subsequent

analyses.

3.3. Psychosocial variables and depression at 4 and

12 months

At 4 months, t-tests revealed that mothers diag-

nosed by interview as having been depressed since the

birth differed from non-depressed mothers in report-

ing their fathers as less caring during childhood, lower

marital satisfaction, a lower score for mature defences;

a higher score for immature defences, a higher score

for discomfort with closeness and a higher score for

anxiety over relationships. They did not differ on

ratings of maternal care, maternal or paternal protec-

tion during childhood, nor on neurotic defences. (See

Table 1 for means and standard deviations and

significance levels.)

Table 2 presents the correlations among the

continuous psychosocial variables measured at 4

months (PBI factors, DAS total score, attachment

style factors, DSQ factors) and CES-D symptom

scores at 4 and 12 months. Intercorrelations among

predictors ranged from 0.015 to 0.515.

3.4. Predicting persistent depression

In the current study, participants were considered

to be suffering from persistent depression if their

score on the CES-D symptom measure at 12 months

was N16, yielding a dichotomous dependent variable.

In addition to maternal education and NESB,

symptom severity at 4 months (measured using the

l

Table 2

Correlations between psychosocial predictorsa and depression

symptoms measured using total score from the CES-D at 4 and

12 months postpartum

CES-D total score

(at 4 months)

(n=100)

CES-D total score

(at 12 months)

(n=100)

Parental Bonding Instrument Factors

Maternal care �0.140 �0.220*

Maternal protection 0.146 0.166

Paternal care �0.083 �0.117

Paternal protection 0.116 0.067

Attachment Style Questionnaire Factors

Discomfort with closeness 0.413** 0.386**

Anxiety over relationships 0.443** 0.427**

Defence Style Questionnaire Factors

Immature 0.361** 0.449**

Mature �0.309** �0.402**

Neurotic 0.203* 0.106

Marital satisfaction

4 months

�0.305** �0.428**

a Psychosocial questionnaires were administered at 4 months.

Low scores for PBI care, mature defences and marital satifaction are

more problematic. High scores for the PBI protection scale, immature

and neurotic defences and ASQ scores are considered problematic.* Pb0.05.** Pb0.01.

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–2420

CES-D) was fitted in a first step in all logistic

regression analyses to control for the subjects’

baseline level of depression.

Table 3

Logistic regression model testing anxiety over relationships as a mediator o

12 months (n=100)

b S.E. Wald

(df=1

Step 1

Depression 0.09 0.04 6.07

Symptoms 4 months

(CES-D)

NESB 1.94 0.69 7.72

Education �0.09 0.37 0.06

Step 2

(PBIa) �0.07 0.04 3.35

Maternal care

Anxiety over 0.13 0.06 4.75

Relationships

(ASQb)

a Parental Bonding Instrument.b Attachment Style Questionnaire.

Both depression symptom score at 4 months and

non-English speaking background were significantly

associated with elevated CES-D scores at 12 months

(Wald v2=13.59, df=1, P=0.00, OR=3.35; Wald

v2=5.04, df=1, P=0.02, OR=1.13), respectively.In order to reduce the number of predictor

variables a preliminary set of analyses was conducted

fitting bfamiliesQ of predictors in separate regression

analyses after controlling for education, NESB and

CES-D scores at 4 months, using backward elimi-

nation (PN0.1). Significant predictors of elevated

CES-D scores (N16) at 12 months were maternal care

during childhood (Wald v2=7.12, df=1, P=0.01,

OR=1.10), anxiety over relationships (Wald v2=6.80,

df=1, P=0.01, OR=1.18), an immature defence style

(Wald v2=7.38, df=1, P=0.01, OR=1.05) and low

marital satisfaction at 4 months (Wald v2=5.04, df=1,P=0.02, OR=1.05).

3.5. Testing mediation models

In order to test whether anxiety over relationships,

immature defence styles or marital satisfaction medi-

ated the relationship between maternal care in child-

hood and clinically elevated symptoms at 12 months, a

series of linear regression analyses were then con-

ducted to determine whether maternal care in child-

hood explained variance in these potential mediator

variables. Maternal care in childhood significantly

f low maternal care in childhood on elevated depressive symptoms at

v2

)

P-value Exp. b(OR)

CI (OR)

0.01 1.10 1.01�1.18

0.00 6.97 1.77�27.46

0.78 0.91 0.44�1.88

0.07 0.93 0.86�1.01

0.03 1.15 1.01�1.29

Table 4

Logistic regression model testing immature defence styles at 4 months as a mediator of impact of low maternal care on elevated depressive

symptoms at 12 months (n=100)

b S.E. Wald v2

(df=1)

P-value Exp. b(OR)

CI

Step 1

Depression 0.12 0.04 9.32 0.00 1.13 1.04–1.21

Symptoms at 4 months

(CES-D)

NESB 1.69 0.70 5.87 0.01 5.41 1.28–21.22

Education �0.17 0.38 0.19 0.66 0.84 0.39–1.79

Step 2

PBIa �0.09 0.04 4.67 0.03 0.92 0.85–0.99

Maternal care

DSQb 0.04 0.02 5.31 0.02 1.05 1.01–1.09

Immature

a Parental Bonding Instrument.b Defence Style Questionnaire.

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–24 21

predicted anxious attachment style (b=�0.26,

t=�2.99, P=0.00, % variance 8.4%), and an immature

defence style (b=�0.70, t=�2.37, P=0.02, % variance

3.6%), with a non-significant trend to predict low

marital satisfaction (b=0.41, t=1.90, P=0.06, %

variance 4%). Consequently, the role of marital

satisfaction as a mediator was not further tested.

Finally, two separate logistic regression analyses

were conducted for the dichotomous dependent vari-

able (CES-DN16 at 12 months) that simultaneously

entered the independent variable (maternal care in

childhood), and the potentially mediating variables

(anxiety over relationships and immature defence style,

respectively), after controlling for depression symp-

toms at 4 months and demographics. The results are

shown in Tables 3 and 4 and demonstrate a significant

mediation effect for anxiety over relationships as the

previously significant relation betweenmaternal care in

childhood and depression symptoms at 12 months is no

longer significant, but not for immature defence styles.

4. Discussion

4.1. Prevalence of depression at 12 months

This study confirms that in this relatively high-risk

sample a significant proportion of women with

postnatal depression (30% of the total sample and

60% of those with elevated symptoms at 4 months

postpartum) continue to report elevated symptoms of

depression 12 months after birth. However, a meta-

analysis (O’Hara and Swain, 1996) has noted that a

higher prevalence of depression is typical in studies

using the CES-D compared with those using the

Edinburgh Postnatal Depression Scale (Cox et al.,

1987). Consistent with the interactive model origi-

nally proposed by Coyne (1976), adverse childhood

events (specifically low maternal care), interpersonal

difficulties (marital satisfaction at 4 months, an

attachment style characterised by anxiety over rela-

tionships) and maladaptive cognitive/coping styles

(specifically an immature defence style) were signifi-

cant predictors of persistence of depressive symptoms.

Furthermore, an insecure attachment style was shown

to mediate the effect of low maternal care in child-

hood, while other cognitive and interpersonal factors

(marital difficulties and immature defence styles)

appeared to work in tandem with adverse childhood

experiences in maintaining depressive symptoms.

4.2. Adverse childhood experiences, interpersonal

difficulties and postnatal depression

The findings provide further support for the

bparents, partners and personalityQ model of vulner-

ability to postnatal depression proposed by Boyce et al.

(1991) confirmed in subsequent research by Matthey

et al. (2000). Results of both earlier studies suggest

that parenting problems during childhood play a more

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–2422

significant role in the onset, and that the quality of the

marital relationship and personality factors are more

important later in the first postnatal year. This

interpretation is extended by our finding that although

low maternal care remained a significant predictor of

persistent depression, the effect was mediated through

an insecure (anxious) attachment style. Anxious

attachment style as measured in the current study is

conceptually very similar to the personality construct

binterpersonal sensitivityQ described by Boyce and

Mason (1996) as an oversensitivity to interpersonal

interactions due to fear of disruptions to the relation-

ship. The link between an insecure attachment style

and diagnosis of depression confirms recent findings

by Bifulco et al. (2004). Interestingly, we found that

both discomfort with closeness (an avoidant style) and

anxiety over relationships were associated with a

diagnosis of depression, while anxiety over relation-

ships predicted persistent symptoms.

Of particular interest in relation to our focus on

exploring factors which might maintain depressive

symptoms are recent laboratory studies demonstrating

that in stressful situations an anxious attachment style

is associated with a tendency to ruminate on negative

thoughts and the employment of emotion-focused

coping strategies (Mikulincer and Florian, 1998).

Furthermore, Alexander et al. (2001), in a study

examining the role of attachment issues during the

transition to parenthood, found that relationship

anxiety was linked to more emotion-focused coping

in women during early parenthood and to subsequent

adjustment difficulties.

Consistent with the findings of Matthey et al.

(2000), the quality of the marital relationship was also

found to be a predictor of depressive symptoms at 12

months. This is not surprising as the partner is likely to

be the primary source of support for mothers through-

out the first postnatal year. In our study, however, a

mediation model involving marital quality was not

supported and the effect of marital satisfaction on

depression symptoms at 12 months was not significant

when maternal care in childhood was included in the

model.

4.3. Maladaptive coping styles; immature defences

As noted above an anxious attachment style may

be associated with emotion-focused coping strat-

egies. The finding in the current study that an

immature defence style predicted persistence of

depression is a new contribution, as defence styles

have not previously been examined in relation to

postnatal depression. Given findings from a number

of studies regarding relatively low uptake and

completion of treatment for postnatal depression

(e.g., O’Hara, 2002), it may be that women with

immature defence styles are less likely to seek help

or persevere with treatment. Although all of the

women in our sample had sought help in the early

postpartum months regarding infant difficulties,

during the course of the study, many women

declined help or dropped out of treatment when the

treatment was specifically directed to depression

(Spielman, 2000).

4.4. Strengths and limitations

The high prevalence of postnatal depression (60%)

and clinically elevated symptoms at 12 months (30%),

compared with rates of around 10% in studies using

community samples (e.g., Da Costa et al., 2000;

Matthey et al., 2000; Boyce et al., 1991) has enabled

us to explore factors associated with probable case-

ness at 12 months, despite the small sample size.

However, the relatively high risk nature of the sample

limits generalisability of our results.

The measurement of psychosocial risk factors at a

time when many of the mothers were concurrently

depressed (at 4 months) is also a limitation. While

reporting on the PBI has been shown to be largely

unaffected by depressed mood (Parker, 1981) Boyce

and Mason (1996) have noted the problem of assessing

personality when confounded by mood state. None-

theless, in the current study, depression symptoms at 4

months were controlled statistically in all analyses.

Reliance on self-report measures is a further

limitation. It is generally acknowledged that self-

report measures of attachment style access only

conscious attitudes and behaviours while the Adult

Attachment Interview (AAI) (George et al., 1985) also

elicits unconscious representations (Stein et al., 1998;

Shaver and Mikulincer, 2002). Furthermore, the

measures differ in focus with the self-report measures

asking about a series of relationships while the AAI

focuses on relationships with the parents during

childhood and currently. Self-report measures often

C. McMahon et al. / Journal of Affective Disorders 84 (2005) 15–24 23

fail to capture avoidant attachment styles due to a

tendency for individuals with avoidant working

models of attachment to normalise and report pos-

itively about themselves (Stein et al., 1998). This may

explain our failure to find discomfort with closeness to

be a significant predictor of depression symptoms at 12

months (although we noted a non-significant trend in

regression analysis). More in-depth research regarding

the relationship between internal working models of

attachment, postnatal depression and problematic

parent–child relationships is needed.

5. Conclusion

Notwithstanding the above limitations, the current

study confirms the importance of early childhood

experiences, interpersonal difficulties and maladaptive

coping styles in maintaining symptoms of depression

in women with postnatal depression. The study also

provides some new evidence that the impact of

adverse childhood experiences is mediated by an

insecure attachment style. Findings regarding the

association between anxious attachment, immature

defence styles and persistent depression in this high

risk sample need to be replicated in community

samples, as they may have implications for screening

of women at risk of ongoing depression and for

provision of effective interventions. Although what

happened during childhood cannot be changed, both

working models of attachment and maladaptive

coping styles are amenable to modification (Cicchetti

et al., 1998; Akkerman et al., 1999). Bloch et al.

(1993) have noted that effective treatment for persis-

tent depression needs to incorporate a psychodynamic

component. The current findings also attest to the

need to prioritise the establishment of supportive

relationships for women with postnatal depression

both in the personal and professional context.

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