Postpartum distress: More than depression
The postpartum period can be a time of vulnerability to distress for many women. Postpartum mental health problems are burdensome for parents, can have serious short and long-term negative impacts for infants, and cause significant costs to health care systems [
1‐
3]. Consequently, detection and treatment of psychological distress in new motherhood is critical [
4,
5]. While historically, clinical and research focus has been on maternal depression symptoms, there is growing recognition of a need to assess a broader range of psychological distress symptoms, such as anxiety, stress, fatigue, and insomnia [
5‐
12]. These symptoms may not necessarily be identified by measures of postpartum depression [
13].
While an estimated 10 to 20% of women experience postpartum depressive symptoms [
14], anxiety symptoms can be equally, if not more prevalent in the post-partum period, and in many cases often co-exist with depressive symptomology [
7,
10,
15,
16]. Less is known about the extent of irritability, a separate unpleasant mood state that predisposes people towards negative emotions, hostile appraisals, and the expression of negative emotions (e.g., anger) towards others [
17,
18]. While irritability may exist in the context of other forms of distress such as depression, some consider it a unique construct in its own right [
17,
18]. Pertinent to the postpartum periods, women may be vulnerable to irritability symptoms due to increases in sleep disturbance [
11,
19,
20].
Fatigue is a common complaint in the postpartum period [
21], yet to the best of our knowledge, not routinely assessed in primary or specialist healthcare settings. Fatigue is subjective feelings of overwhelming exhaustion or tiredness that reduces physical and cognitive capacities to function [
22,
23], and can be caused by physical, psychological, and environmental factors [
24]. Approximately 60% women report elevated fatigue in the first months after giving birth [
21]. While fatigue is one of the DSM-5 diagnostic criteria for depressive disorders [
25], a growing body of evidence suggests that postpartum fatigue and depression are
related but separate constructs [
9,
26‐
28].
Insomnia symptoms are common but have been scarcely researched in the postpartum period [
8]. With 40–60% of women who have recently given birth reporting insomnia symptoms [
8]. Insomnia symptoms include persistent difficulties in falling asleep, staying asleep, waking too early, or having unrefreshed sleep despite adequate sleep opportunity and conducive sleep environment, and is accompanied by impairments in daytime functioning [
29]. Assessment of insomnia may assist with early detection and treatment of other forms of psychological distress such as depression, which insomnia symptoms can precede and/or perpetuate [
30].
Impulsivity is another under-examined area of postpartum distress. It refers to a pattern of behavior that involves failing to inhibit rapid and unplanned responses to stimuli [
31‐
33]. Higher impulsivity is associated with symptoms of depression, anxiety, as well as maladaptive behaviors such as suicidal behavior and substance use in adults [
33,
34]. Impulsivity may be particularly relevant for women in the postpartum period as greater impulsivity has the potential to negatively impact maternal-infant relationship. For example, more impulsive parents have been found to be more critical of their children in later childhood [
35]. Moreover, individuals react in a more impulsive state to negative emotional stimuli after just one night without sleep [
31] which is particularly relevant to women in the postpartum period due to their increased vulnerability to sustained sleep disturbance [
36‐
38].
Unsettled infant behavior and vulnerability to psychological distress
Unsettled infant behavior (UIB) refers to infants’ persistent crying, resistance to settling, short sleep intervals and frequent awakenings [
39]. It is reported by up to 25% of parents, has complex causes, is difficult to treat, and is distressing for parents [
39,
40]. Women seeking help with UIB have reported elevated depression, anxiety, stress, fatigue and demoralization symptoms [
41‐
43]. In Australia, there are specialist public and private residential programs that help parents manage UIB (see details in the Methods).
Past research has shown that attending residential early parenting programs that assist with the management of UIB were associated with reductions in maternal depression, anxiety, stress, fatigue and demoralization symptoms [
41,
44,
45]. However, neither the extent nor change in a broad range of forms of psychological distress, including irritability, insomnia and impulsivity symptoms, has been explored in this setting.
Using both self-report measures and computerized tasks, this study aimed to characterize psychological distress symptoms in women seeking assistance with UIB, fatigue and psychological distress at a residential early parenting program, and examined reliable and clinically significant change in symptoms/scores from the start to the end of the program.