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-being1,3.
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.
Table of Contents
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 States1,2,5.
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 complications6,7.
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.
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 depression2,5,7-9. 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 status10,11. 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 spouse12,13. 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.
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.
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 Scale14,15,17. 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 infant1,2. 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 birth6,7.
Within the military community, perinatal depression studies are limited and have identified frequent relocations and deployments as military-specific risks for perinatal depression2-5,7,9. 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.
1. Klaman SL, Turner K. Prevalence of Perinatal Depression in the Military: A Systematic Review of the Literature. Matern Child Health J. 2016;20(Suppl 1):52-65. 2. Schachman K, Lindsey L. A resilience perspective of postpartum depressive symptomatology in military wives. J Obstet Gynecol Neonatal Nurs. 2013;42(2):157- 167.
3. Silverman ME, Reichenberg A, Savitz DA, et al. The risk factors for postpartum depression: A population-based study. Depress Anxiety. 2017;34(2):178-187. 4. Wilkinson A, Anderson S, Wheeler SB. Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis. Maternal Child Health J. 2017;21(4):903-914.
5. Tarney CM, Berry-Caban C, Jain RB, Kelly M, Sewell MF, Wilson KL. Association of Spouse Deployment on Pregnancy Outcomes in a U.S. Military Population. Obstet Gynecol. 2015;126(3):569-574.
6. Yim IS, Tanner Stapleton LR, Guardino CM, Hahn-Holbrook J, Dunkel Schetter C. Biological and psychosocial predictors of postpartum depression: systematic review and call for integration. Annu Rev Clin Psychol. 2015;11:99-137.
7. Appolonio KK, Fingerhut R. Postpartum depression in a military sample. Military Medicine. 2008;173(11):1085-1091.
8. Spooner S, Rastle M, Elmore K. Maternal depression screening during prenatal and postpartum care at a Navy and Marine Corps military treatment facility. Military Medicine. 2012;177(10):1208-1211.
9. Do T, Hu Z, Otto J, Rohrbeck P. Depression and suicidality during the postpartum period after first time deliveries, active component service women and dependent spouses, U.S. Armed Forces, 2007-2012. MSMR. 2013;20(9):2-7.
10. Blakely G, Hennessy C, Chung MC, Skirton H. A systematic review of the impact of foreign postings on accompanying spouses of military personnel. Nurs Health Sci. 2012;14(1):121-132.
11. Blakely G, Hennessy C, Chung MC, Skirton H. Adaption and adjustment of military spouses to overseas postings: an online forum study. Nurs Health Sci. 2014;16(3):387- 394.
12. Blakely G, Hennessy C, Chung MC, Skirton H. The Impact of Foreign Postings on Accompanying Military Spouses: An Ethnographic Study. Health Psychol Res. 2014;2(2):1468.
13. Crouch CL, Adrian AL, Adler AB, Wood MD, Thomas JL. Military Spouses Stationed Overseas: Role of Social Connectedness on Health and Well-Being. Military Behavioral Health. 2017;5(2):129-136.
14. Weis KL, Lederman RP, Walker KC, Chan W. Mentors offering maternal support reduces prenatal, pregnancy-specific anxiety in a sample of military women. Journal of Obstetric, Gynecologic, & Neonatal Nursing: Clinical Scholarship for the Care of Women, Childbearing Families, & Newborns. 2017;46(5):669-685.
15. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786. 16. Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician. 2010;82(8):926-933.
17. Health, G. (2019, April 18). Self Esteem: Rosenberg-SES. Retrieved August 01, 2020, from https://help.greenspacehealth.com/article/91-self-esteem-rosenberg-ses 18. United States, Department of Defense, Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy. (n.d.). 2018 Demographics Profile of the Military Community.