Suicidal ideation in depressed postpartum women: Associations with childhood trauma, sleep disturbance and anxiety
Introduction
Suicide is one of the leading causes of death in postpartum women (Oates, 2003). Recent findings suggest that suicide is the seventh leading cause of maternal death within 6 months of delivery (1.27 per 100,000 maternal deaths) (Lewis et al., 2011). Major depression, bipolar disorders, alcohol and substance use disorders, schizophrenia, and anxiety disorders contribute to the increased risk for suicide and suicidal behaviors (Hawton and van Heeringen, 2009, Oquendo et al., 1997, Rihmer et al., 1995, Fawcett et al., 1990, Cornelius et al., 1995, Nepon et al., 2010, Busch et al., 2003, Sareen et al., 2005). In the postpartum period, women with a psychiatric disorder, substance use disorder or both disorders were at significantly increased risk for suicide attempts by 27, 6 and 11-fold, respectively (Comtois et al., 2008). Of mothers who died from suicide in the first 6 months after childbirth, the primary diagnoses were severe depression in 21%, substance use disorders in 31% and psychosis in 38% (Lewis et al., 2011).
The inadequate assessment of risk or illness severity (Lewis et al., 2011) plus low rates of seeking mental health treatment (15% of postpartum women with major mood disorders) (Vesga-López et al., 2008) likely compound the risk for suicide in postpartum women (Fawcett et al., 1990, Oquendo et al., 1997). Beyond risk to mothers themselves, maternal suicidality can undermine mother–infant interactions. Mothers with suicidal symptoms display reduced responsiveness and sensitivity to infant cues; their infants have less positive affect and reduced engagement with their mothers (Paris et al., 2009).
In addition to psychiatric disorders, other risk factors for suicide or suicidal ideation (SI) in adults include a history of self-harm or suicide attempts (Cavanagh et al., 2003, Hawton and van Heeringen, 2009), suicidal thoughts (Coryell and Young, 2005, Fawcett et al., 1990), a family history of suicide (Brent et al., 1988, Hawton and van Heeringen, 2009, Oquendo et al., 1997, Roy, 1983) and increased levels of hopelessness (Fawcett et al., 1990, Beck et al., 1985). Experiences of childhood physical abuse, sexual abuse and neglect are significantly associated with suicide attempts and thoughts of suicide in the general community (Fuller-Thomson et al., 2012, McCauley et al., 1997, Dube et al., 2001, Joiner et al., 2007, Enns et al., 2006) and in patients with major depressive disorders (Brown et al., 1999, Brodsky et al., 2001, McHolm et al., 2003, Oquendo et al., 2005, Widom et al., 2007). Among severely depressed patients proximal risk factors for suicide and suicidal behaviors include acute intoxication (Oquendo et al., 1997), sleep disturbance (insomnia or nightmares) (Bernert et al., 2005, Fawcett et al., 1990) and heightened symptoms of anxiety or agitation (Busch et al., 2003, Fawcett et al., 1990).
The reduction of suicide risk in mothers with major mood disorders is a public health priority. After delivery, women with postpartum major depression, puerperal psychosis and recurrent episodes of Bipolar Disorder (BD), often had thoughts of self-harm or SI (Wisner et al., 2013, Howard et al., 2011, Sit et al., 2006, Pope et al., 2013). Findings from a postpartum depression screening program of 10,000 women, indicated postpartum women who screened positive for depression had high rates of self-harm ideation (19.3%) and frequent thoughts of self-harm (3.2%) (Wisner et al., 2013). Depression screening of 4000+ postpartum women in the community also suggested 4% had frequent thoughts of self-harm “sometimes” or “quite often” (Howard et al., 2011).
To understand the risk of suicide or thoughts of self-harm in postpartum women, we can begin by exploring the known risk factors for suicide or SI in adults with and without major mood disorders. Given the compelling findings from our group (Wisner et al., 2013) and others (Howard et al., 2011, Paris et al., 2009, Pope et al., 2013), we conducted secondary analyses to determine whether the known risk factors for suicidal symptoms in adults with and without mood disorders also applied to women after childbirth. Our study aim was to examine associations between SI and plausible risk factors (trauma history i.e. the experience of abuse in childhood or as an adult, sleep disturbance, and anxiety symptoms) in depressed postpartum women. The hypothesis was the experience of childhood abuse, current sleep disturbance, and increased levels of maternal anxiety would be associated with increased thoughts of self-harm in depressed postpartum women at 4–6 weeks after childbirth.
Section snippets
Methods
In the earlier report, we described in detail the design and methodology of the original postpartum depression (PPD) screening study approved by the University of Pittsburgh Institutional Review Board (Wisner et al., 2013). Postpartum women were enrolled in a depression screening program based at a major obstetrical hospital (Wisner et al., 2013). On the maternity ward, nurses or social workers approached women who delivered a live infant, provided information about PPD, and offered depression
Patient characteristics
The study patients included 628 women with a positive depression screen (EPDS ≥ 10) and an SCID-confirmed diagnosis of a primary depressive or anxiety disorder (Fig. 1 – consort chart). The vast majority of patients had depressive disorders (568/628, 90.4%) of whom most had major depressive disorder (516/568, 90.4%), either recurrent (373/516, 72.3%) or single episodes (143/516, 27.7%); 39 had depressive or mood disorder NOS; and 13 had either an adjustment disorder with depressed mood or
Discussion
As hypothesized, depressed postpartum women who experienced childhood physical abuse were at significantly increased risk for frequent thoughts of self-harm. Other reports similarly indicated a 3–4-fold increased risk for SI (Brown et al., 1999, Enns et al., 2006, Fuller-Thomson et al., 2012, McCauley et al., 1997, McHolm et al., 2003) or suicide attempt (Brodsky et al., 2001, Dube et al., 2001, Joiner et al., 2007) in non-puerperal women with MDD and adverse childhood experiences (Brown
Disclosures
Dr. Sit received a donation of study light boxes from Uplift Technologies (2009) and compensation for providing consultation on Lauren Alloy's R01 grant (2014). Dr Wisner participated in an advisory board for Eli Lilly Company and received donated estradiol and placebo transdermal patches from Novartis for a National Institute of Mental Health-funded randomized trial, activities that do not involve the work described in this article. Dr Wisniewski has received compensation for consultation to
Contributors
The staff at Magee-Womens Hospital including Terri Redpath, RN, Veta Farmer, MSW, Leah Kelly, MSN, Darla Lane, RN, Rosanne Salt, RN, Jeanne Kingston, RN, Jessica Lott, RN, Lisa Karow, RN, Lisa Stein, RN, and Karen Pennington, RN, offered screening to new mothers. The clinicians at Women's Behavioral HealthCARE, Western Psychiatric Institute and Clinic Mary McShea, David Rizzo, Carolyn Hughes, Rebecca (Becky) Zoretich, Michelle Costantino, Rachel San Pedro and Christopher Famy, MD provided the
Conflict of interest
The authors declare that there are no conflicts of interest.
Acknowledgments
This study was supported by grant R01 MH 071825 for Identification and Therapy of Postpartum Depression (Dr Wisner, principal investigator). Dr. Sit was supported by a K23 Career Development Award, grant K23 MH082114 on Light Therapy for Bipolar Disorder (PI: D. Sit; 2009–2014) and the 2013 NARSAD Young Investigator Grant on Neural and Visual Responses to Light in Bipolar Disorder: A Novel Putative Biomarker.
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