Perinatal Depression in Military Spouses Stationed Overseas: A Systematic Literature Review

 

Perinatal depression is considered one of the most common complications arising during pregnancy or the postpartum period for women, affecting anywhere between 5%- 25% of women¹. The American Psychiatric Association classifies perinatal depression as a major depressive episode originating during pregnancy or within four weeks of delivery¹.

Perinatal depression (PND) is considered a major mental health condition characterized by excessive fatigue, solemnness, anxiety, appetite and sleep disturbances, and the overall ideation of inadequacy and inability to cope with  mothering². In addition to the negative personal implications perinatal depression can have on the mother,  studies also have indicated that perinatal depression can cause significant issues in infant development and well-being^1,3.

Perinatal depression has been associated with failure to breastfeed, impaired infant bonding, delayed infant development, and the infant’s inability to thrive. Perinatal depression also is associated with strained marital or relationship issues, suicide, and even infanticide⁴. Children of mothers with perinatal depression have been shown to have developmental or cognitive delays, decreased language skills, impaired social skills, and overall behavioral disturbances².  

Studying Perinatal Depression

Perinatal depression has been widely studied among the civilian population with a prevalence of 5% to 25%¹. This variation in prevalence is attributed to varying screening methods used, as well as different time periods post-birth². There have been limited studies on the prevalence of perinatal depression among military spouses. However, there are wide variations in the few studies available.

None of the current studies account for overseas duty stations, including only women living within the U.S. Furthermore, many of these studies are examining perinatal depression prevalence within the military active duty population, not military spouses. There have been several studies that examine military spouses specifically identifying the risk in those whose significant others are currently or soon-to-be deployed, although these studies are of women within the United States^1,2,5.

Methods

A comprehensive search was performed in both PubMed and EBSCO using MeSH terms.  In PubMed, the search for “perinatal depression (MeSH)” resulted in 2,052 articles. “AND military spouse” was added to further narrow results, leaving four articles. A repeat was performed with “postpartum depression (MeSH),” resulting in 5,489 articles. “AND military”  was added, resulting in 23 articles. If you further added “AND military spouse” only seven articles remained.

Articles that included a study on U.S. military women and/or military spouses were retained and exported to EndNote X9. The EBSCO search is comprehensive of many databases, including the Cochrane library and Medline.

Postpartum depression (MeSH) was searched in the EBSCO database resulting in 66,892 articles. “AND” military was added, further narrowing it to 835 articles. “AND military spouse” finalized the search to 18 articles. Duplicate articles were removed and the remaining articles were downloaded into EndNote X9. Ten articles were selected for review. A second search was performed to stratify the psychosocial implications of military spouses stationed in foreign countries. In PubMed, the search for  “military spouse (MeSH)” resulted in 235 articles. “AND overseas” was added to further narrow it to nine articles. 

Previously Identified Risks for Perinatal Depression

In the civilian population, several studies have identified certain psychosocial factors placing a woman at higher risk for developing perinatal depression. These identified factors include stressful life events, an unsupportive spouse or significant other, relationship problems, an unsupportive mother, existing anxiety or depression, lack of social support, infant temperament, and infants born with complications^6,7.

One literature review analyzing the risk factors associated with PND indicates stress has most consistently been one of the highest associations with PND, especially if the stress is associated with another social, psychological, or biological vulnerability⁶. Multiple studies have been conducted indicating that stressful life events experienced during the prenatal or the postpartum period could place a woman at higher risk for PND⁶.

Another type of stress shown to contribute to PPD risk is parenting stress; this is when there is a considerable perceived imbalance in parenting demands and the resources available to alleviate or reduce that demands⁶. Parenting stress showed a significant correlation with a higher prevalence of PND  when compared to women who did not experience this perceived stress⁶.  

Military-specific Stressors

Within the military community itself, there have been several studies conducted that indicate active duty servicemembers are at a higher risk for perinatal depression⁷. Furthermore, several studies demonstrate that deployment, of the female servicemember herself or of the spouse/significant other, significantly increases the mother’s risk for perinatal depression^2,5,7-9. One study in particular identified that dependent spouses diagnosed with postpartum depression were 14.5 times more likely to be diagnosed with some form of suicidality9. This same study indicated that an active duty servicemember diagnosed with PND was 42.2 times more likely to be diagnosed with suicidality than a servicemember who had not experienced PND⁹. These studies have contributed to increased provider awareness within the military medical community, emphasizing the importance of appropriate screening and treatment methods for women who meet any of the identified risk factors.  

Military spouses experience loss in several ways throughout the servicemember’s career.  This may be a loss of job, community, and support. This overall combined loss can contribute to a feeling of lost identity and a feeling of worthlessness¹⁰. The perception of repeated or significant loss of identity also can contribute to increased stress; this can ultimately affect the overall well-being of the individual¹⁰. Oftentimes, at military installations, the spouse becomes identified by the servicemember. He or she is referred to as the “dependent” or “wife/husband- of ___” instead of being recognized for his/her own accomplishments or status^10,11. This contributes to an overall loss of identity.  

Military Spouses in Foreign Territories

According to the 2018 Demographics report, 91.3% of active duty spouses are women,  the average age is 31.6 years old and there are 69,708 military spouses living outside of the continental U.S.¹⁸. There are no studies specifically researching the prevalence and/or risk of PND in military spouses who are living overseas in a foreign territory. Therefore, we will analyze the few studies available that identify the psychosocial implications of being a military dependent in a foreign country and use that information to theorize the potential risk for PND.

There were two studies in the UK that assessed the impact of being an accompanying military spouse during a military posting. It was determined that the spouse’s sentiments toward the experience were a  combination of the direct reflection of his/her attitude, the strength of the spousal relationship, the support network available and/or formed, resources available, previous experiences, and ability to  adapt¹². Although many spouses felt the experience was overall positive, there were many who reported experiencing significant distress during this time, more often if there was a lack of family support¹².  

Relocation Stressors and Culture Shock

There has been documented research studying military spouses within the U.S.  highlighting the importance of social support systems for military families to properly adjust to new locations¹³. Frequent geographic relocations are associated with recurring loss of social support systems¹¹. In fact, it is reported that perceiving this loss can significantly impact the overall health and well-being of a military spouse^12,13. Therefore, the ability to form a social network is vital to establishing a support system. Otherwise, the inability to do this was found to be a significant disadvantage of being overseas¹².  

Many of the spouses reported increased stress related to the relocation. This in large part was attributed to the overall culture shock of the foreign territory¹⁰. Furthermore, many of the spouses experienced difficulty finding employment and this directly contributed to financial strain. Many spouses also reported difficulty with communication barriers within the community.  The employment and communication barriers also were shown to directly contribute to overall  stress¹⁰. 

The study’s main limitation is that it was a small sample size. Both were limited to  British families. Although there are other studies available regarding the stressors of overseas military postings, they are very outdated and nearly all over 12-20 years old, and therefore were not included in this review. Updated studies that are more reflective of the experiences of the modern military spouse with today’s available technology would prove more helpful in determining how a foreign post affects these new mothers.  

Discussion

Copious amounts of research among the civilian population have clearly identified multiple perinatal depression psychosocial risk factors consistent throughout many studies. Although there is no specific study available that assesses the risk of perinatal depression in the military spouse at a foreign posting, a hypothesis can be derived by analyzing the information available at this time.  

Women who accompany their military spouse to a foreign posting are required to uproot from their current support network and integrate into a new community with the added difficulty of experiencing the culture shock of another country. The existing research highlights that relocation to a foreign territory is associated with a loss of social support networks and increased stress levels. Appropriate support networks are vital in preventing perinatal depression and a lack of adequate support is directly related to a significant increase in risk for perinatal depression. Therefore, it would be reasonable to theorize that the loss of support systems when relocating overseas could contribute to a higher perinatal depression risk for this population of women.  

The Importance of Support Systems

Whenever making this drastic physical move, women do not only lose their social support network, but also their extended familial and resource support. Having to pack up and move to the opposite side of the world can have significant emotional ramifications and impact relationships with family members. Additionally, as described above, a woman’s poor relationship with her mother could also contribute to her risk of perinatal depression. This isolation from family, straining relationships, and placing a geographical blockade to support within the postpartum period most likely contributes to an increased risk of perinatal depression. 

Relocation to a foreign post was consistently associated with increased perceived stress.  This stress was attributed to both cultural shock as well as barriers within the new community.  Stress has been identified on multiple occasions to directly increase the risk for perinatal depression. Therefore, it would be reasonable to extrapolate that the significant stress of relocating to a foreign territory, along with the daily stressors induced by the barriers of the foreign community, could increase a  woman’s risk for perinatal depression.  

Deployment-related Stress

Military-specific risk factors, such as the deployment of the woman’s spouse before, during, or after birth, have demonstrated association with a significant increase in risk for perinatal depression. If a  deployment occurs shortly after relocation or while assigned to a foreign post, this may be especially difficult and stressful for the woman during the perinatal period. Not only would she have the identified risk of spousal deployment, but she also would be entirely dependent on a social support system that may or may not be in place. Should she not have an adequate support network, this would most likely increase her probability of experiencing perinatal depression.

Furthermore, should the spouse be deployed during the postpartum period, she also will likely experience the added parental stress of becoming a single parent during the deployment period. With the clearly identified risk factors of stress and deployment, women in this particular situation likely would be especially vulnerable to perinatal depression.  

Finding Community with MOMS

The military community has recognized the significance of appropriate perinatal care and the particular associated stressors not experienced within the civilian population. The military launched the MOMS study (Mentors Offering Maternal Support) which is ongoing in several branches at this time. The purpose of this study was to identify whether this support program was able to significantly reduce anxiety and depression related to pregnancy, as well as to improve resilience and self-esteem among the military women community¹⁴.  

This study uses self-reported questionnaires to identify and measure perinatal anxiety.  Active duty women and dependent spouses are enrolled during the first trimester and randomly assigned to either the MOMS or control group. The women were given questionnaires during the second and third trimesters that incorporated the PSEQ-SF (measures prenatal anxiety), the Rosenberg Self-Esteem Scale, the Edinburgh Postnatal Depression Scale (EPDS), and the Brief Resilience Scale^14,15,17. Women in the MOMS group attended an additional mentor-led support group while the control group proceeded only with routine prenatal care. This study concluded that the MOMS program was effective in decreasing prenatal anxiety and laid the groundwork to increase community care and support collaboration¹⁴.

Although this study is progressing in the appropriate direction for perinatal care within the military community, the study does not effectively evaluate perinatal depression during the postpartum period and focuses more on prenatal anxiety.  Ideally, this study could be expanded further into the postpartum period to elaborate on the risk of perinatal depression in this subset of women. 

Perinatal Depression Affects Families

Perinatal depression is a serious mental health condition that has been shown to have negative implications for both the mother, spouse, and infant^1,2. Certain psychosocial risk factors have been well identified within the civilian community, such as relationship strain, stress, lack of social support, underlying depression and/or anxiety, and complications with the infant at birth^6,7.

Within the military community, perinatal depression studies are limited and have identified frequent relocations and deployments as military-specific risks for perinatal depression^2-5,7,9. Military spouses who accompany their partners on relocation to another country are geographically isolated from family and their established social support networks. The implications of moving to a foreign territory result in a culture shock with an associated lack of social support, at least initially, as well as increased overall stress.

Screening for Perinatal Depression

These identified implications also are considered identified risk factors for increased likelihood of perinatal depression. Although a specific study has not been conducted at this time, it would be reasonable to theorize that this would absolutely result in an increased risk of perinatal depression for this population of military spouses. Therefore, appropriate resources and screening should be in place at foreign military installations to ensure this subset of military spouses is adequately supported.

Medical professionals in these installations should be hypervigilant in screening for perinatal depression and ensuring appropriate follow-up measures are being taken. Further research is needed to produce statistically significant data to support this hypothesis and to demonstrate whether this special population is at an increased risk for perinatal depression.