An exploration of illness beliefs in mothers with postnatal depression

Abstract

Objective

to explore illness beliefs in women with postnatal depression and suggest an appropriate health belief model. About 10% of recently delivered mothers suffer from depression. Postnatal depression may differ from depression occurring at other times in an individual's life not only symptomatically but also experiences, perceptions and beliefs about the illness differ because of the individual's specific role as a carer for a newborn baby. Whilst illness beliefs have been extensively examined using models from physical health, recent studies have pointed out that physical health models may not provide an appropriate framework to explore mental health difficulties and require adapting.

Design

qualitative study using face-to-face interviews for data collection.

Setting

Greater Manchester, England.

Methods

as illness beliefs have not yet been formally assessed using established questionnaires, the present study employed qualitative methodology to explore illness beliefs in mothers with postnatal depression (PND). Semi-structured interviews were conducted with 11 participants who were depressed following the birth of their child. Interview transcripts were analysed using grounded theory methodology. The point of theoretical sufficiency was reached with this sample size.

Findings

the rich data allowed for a theory of illness beliefs in PND to be developed encompassing six core categories: ‘unmet expectations’, ‘identifying stressors in their life context’, ‘conflict over label’, ‘antidepressants: the lesser of two evils’, ‘loss of time’ and ‘uncertain futures.’

Key conclusions and implications for practice

participants made multiple appraisals of their PND in light of their initial difficulties, their improvements and consequences, the future and subsequent service involvement. Participants' narratives were conflicting and uncertain with internal struggles evident as mothers were torn between their desire to be good mothers and their perceptions that PND meant that they were not good enough mothers. Thus, the themes identified in this study did not match onto the key dimensions postulated by Leventhal's self-regulation model of illness beliefs.

Introduction

Low mood occurring in the postnatal period encompasses childbirth mood disorders from the baby blues to serious psychiatric illness, affecting 10–20% of mothers after childbirth (e.g., Hopkins et al., 1984). Studies indicate that clinical symptoms of mood disturbances following childbirth are not significantly different from illnesses that affect women at other times in their lives but certain aspects may be more pronounced (Kumar and Robson, 1984, Cox et al., 1993). Although postnatal mental disorders are important to understand and improve because they can significantly impact on both the functioning of the family and the child's long-term emotional and cognitive development (Murray et al., 1996; Hay et al., 2001), it is particularly important to keep mothers central in care because they suffer.

Historically, it has been difficult to identify or treat PND and this may be linked to several factors: some mothers may dismiss it as the ‘baby blues’; others may feel ashamed to admit they are not enjoying motherhood especially at a time that is supposed to be joyous (Beck, 1993). Additionally, some may worry that social services will remove their baby from their care (Edwards and Timmons, 2005). Over the last 40 years there has been a wealth of research into PND and the psychosocial risk factors associated with its development (e.g., Boyce and Hickey, 2005, Yelland et al., 2010, Woolhouse et al., 2011). Qualitative designs have frequently been used to capture the voices of mothers. In a metasynthesis of 18 qualitative studies, Beck (2002) identified four over-arching themes to conceptualize PND: incongruity between expectations and reality of motherhood, spiraling downward, pervasive loss and making gains. Although these existing studies provided valuable insight into maternal experiences of PND, no research has sought to examine mothers' beliefs about their PND. Understanding patient beliefs about their condition can be a useful way of predicting behaviour and outcomes.

Leventhal's self-regulatory model (SRM; Leventhal et al., 1984) has been used extensively to examine health beliefs; postulating that illness cognitions have key dimensions: identity, cause, timeline, consequences and cure/control. According to this model, patients create illness dimensions once symptoms are experienced and these determine coping, help-seeking behaviours (including accessing formal and informal support) and treatment adherence. The SRM has been employed successfully to assess patient beliefs in various chronic medical conditions, such as chronic fatigue syndrome (Moss-Morris et al., 1996), atopic dermatitis (Wittkowski et al., 2007) and rheumatoid arthritis (Treharne et al., 2005).

The SRM has also been used to explore illness beliefs in mental health problems. Illness perceptions have been explored using standardized measures (e.g., the Illness Perception Questionnaire, IPQ; Weinman et al., 1996) within anorexia nervosa (Holliday et al., 2005), psychosis (Broadbent et al., 2008), and depression (Brown et al., 2001, Fortune et al., 2004). The IPQ has also been modified for patients with psychosis/schizophrenia (Lobban et al., 2003, Watson et al., 2006) and their carers (Barrowclough et al., 2001). Although these studies indicate the applicability of illness perceptions across a range of mental health difficulties, their limitations have also been highlighted. In schizophrenia not all SRM variables had any relation to their outcome variables (Barrowclough et al., 2001). As it is important to consider that the underlying beliefs of those with mental health difficulties may differ from those patients with physical conditions, it is important to develop more sophisticated ways of investigating these; with qualitative methodologies being a valuable tool. Few qualitative studies have addressed this area. Existing findings demonstrate that patients with mental health difficulties form cognitive representations of their condition (Pollack and Aponte, 2001, Kinderman et al., 2006), but applying health models to mental health is not straightforward. In patients with anorexia nervosa beliefs about their illness were not static and their accounts transcended the SRM dimensions (Higbed and Fox, 2010). Researchers have recommended that significant modifications to these health models are needed to make them applicable to mental health problems and to capture a full understanding and the complexity of perceptions (Kinderman et al., 2006, Higbed and Fox, 2010). Thus, further studies using qualitative methodologies need to be undertaken to add strength to these findings.

Exploring mothers' views of their PND is crucial because it may lead to opportunities to better support them and tailor interventions more appropriately. This study set out to explore illness beliefs in mothers with PND to develop a theoretical understanding of these illness beliefs.