http://informahealthcare.com/pog ISSN: 0167-482X (print), 1743-8942 (electronic) J Psychosom Obstet Gynaecol, 2014; 35(3): 84–91 ! 2014 Informa UK Ltd. DOI: 10.3109/0167482X.2014.947953
ORIGINAL ARTICLE
Rates and risk factors associated with depressive symptoms during pregnancy and with postpartum onset J Psychosom Obstet Gynaecol 2014.35:84-91. Downloaded from informahealthcare.com by Kainan University on 04/06/15. For personal use only.
Nancy Verreault1,2, Deborah Da Costa1,3, Andre´ Marchand2, Kierla Ireland1, Maria Dritsa1, and Samir Khalife´4 1
Division of Clinical Epidemiology, McGill University Health Centre, Montre´al, QC, Canada, 2Department of Psychology, Universite´ du Que´bec a` Montre´al, Montre´al, QC, Canada, 3Department of Medicine, McGill University, Montre´al, QC, Canada, and 4Department of Obstetrics and Gynecology, Jewish General Hospital, Montre´al, QC, Canada Abstract
Keywords
The objectives of this study were to evaluate the prevalence of depressive symptoms in the third trimester of pregnancy and at 3 months postpartum and to prospectively identify risk factors associated with elevated depressive symptoms during pregnancy and with postpartum onset. About 364 women attending antenatal clinics or at the time of their ultrasound were recruited and completed questionnaires in pregnancy and 226 returned their questionnaires at 3 months postpartum. Depressed mood was assessed by the Edinburgh Postnatal Depression Scale (EPDS; score of 10). The rate of depressed mood during pregnancy was 28.3% and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new postpartum cases. In the present study, belonging to a non-Caucasian ethnic group, a history of emotional problems (e.g. anxiety and depression) or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and having experienced stressful events were associated with elevated depressed mood during pregnancy. Four risk factors emerged as predictors of new onset elevated depressed mood at 3 months postpartum: higher depressive symptomatology during pregnancy, a history of emotional problems, lower social support during pregnancy and a delivery that was more difficult than expected. The importance of identifying women at risk of depressed mood early in pregnancy and clinical implications are discussed.
Depressed mood, perinatal period, prevalence, risk factors
Introduction Depression during pregnancy is common, affecting 8.5–11% of women [1,2]. With respect to the postpartum period, a meta-analysis by O’Hara and Swain [3] found an average prevalence rate of 13%, while a more recent meta-analysis by Gavin et al. [1] reported rates of minor or major depression in the range of 6.5–12.9% over the first year postpartum. The consequences of perinatal depression on both mother and infant are significant and have been well documented [4–6]. Most prospective studies examining both pre- and postnatal depression have found that depressive symptoms are more prevalent or more severe during pregnancy compared to the postpartum period [7–13]. A few studies also suggest that depression during pregnancy tends to persist into the postpartum with about half of postpartum depression cases continuing from pregnancy [11,13,14]. The prevalence of depression with postpartum onset has been found to be between 3.4% and 8.6% [8,11,13–18]. The difference in rates Address for correspondence: Nancy Verreault, Division of Clinical Epidemiology, McGill University Health Centre, 687 Pine Avenue West, Montreal, QC H3A 1A2, Canada. Tel: +514 934 1934 ext: 44723. Fax: +514 934 8293. Email: [email protected]
History Received 11 November 2013 Revised 16 July 2014 Accepted 21 July 2014
of postpartum depression (PPD) observed across studies with varying methodology highlights the importance of prospectively studying the course of depression and associated risk factors at different times over the perinatal period. Lancaster et al. [19] conducted a literature review examining risk factors associated with prenatal depression. Among these risk factors, the presence of co-morbid anxiety, stressful life events, domestic violence, relationship difficulties, poor social support, a history of depression and unplanned pregnancy were most strongly associated with depression during pregnancy. Other factors such as younger age [2], foreign citizenship or membership in a specific ethnic/racial group [2,18,20,21], low self-esteem [22], a negative cognitive style [22], a history of abuse [22,23], chronic health problems [2], and obstetric complications [24] have also been found to be related to prenatal depression. Factors related to marital and socioeconomic status have been found to be associated with both pre- and postnatal depression, but these results have been less consistent and have smaller effect sizes [21,25,26]. Risk factors associated with PPD are numerous and have been widely studied without always distinguishing between PPD depressive symptoms that are persistent or reoccur from
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DOI: 10.3109/0167482X.2014.947953
Factors associated with depressive symptoms during pregnancy and with postpartum onset
pregnancy compared to those with postpartum onset. Metaanalyses have been carried out to estimate the magnitude of the effect size for each risk factor [3,20,27,28]. Among the factors studied in relation to postpartum depression, a history of depression, prenatal depression and/or anxiety, stressful life events, poor social support, negative cognitive style, low selfesteem, lower marital satisfaction and higher childcare stress have been found to be most strongly associated with PPD (i.e. moderate to strong effect sizes) [27,28]. Despite the numerous risk factors that have emerged in the literature, very few studies have excluded women who were already experiencing prenatal depression from their analyses, thus incorporating a source of bias. Among studies that have specifically excluded women with prenatal depression, the following factors have been found to predict depression with postpartum onset: lower socioeconomic status [17,18], previous psychiatric problems, pre-pregnancy obesity, living alone [21], a more negative perception of parental care in one’s own childhood, having suffered stressful events [17], elevated prenatal depressive symptomatology [16], and using assisted reproductive technology [22]. A limited number of studies have compared risk factors for depression during pregnancy with risk factors for PPD [10,22–24,29]. Leigh and Milgrom [29] identified prenatal depression, a history of depression and a higher level of parental stress as risk factors specific to PPD. A study by Mora et al. [23] found comorbid mental health problems, having other children in the household and a lower educational level as factors specific to PPD, while ambivalence toward pregnancy was a risk factor for prenatal depression. In conclusion, very few studies have prospectively evaluated the prevalence of perinatal depression by distinguishing between the percentage of women experiencing elevated depressive symptoms during pregnancy from those who have depressive symptoms with onset in the postpartum period. Moreover, while some studies have evaluated risk factors for pre- or postnatal depression, very few have compared the risk factors specific to each stage. A better understanding of the risk factors associated with elevated depressive symptoms at each stage of the perinatal period would permit a more effective identification of at-risk women and the earlier development of tailored interventions. This study aimed to evaluate the prevalence of elevated depressive symptoms in the third trimester of pregnancy and at 3 months postpartum. We provide estimates of elevated postpartum depressive symptoms with postpartum onset and postpartum depression that persists or reoccurs from pregnancy. This study also sought to prospectively identify risk factors associated with elevated depressive symptoms in the third trimester of pregnancy and to new-onset postpartum depressive symptoms. We hypothesized that there are different risk factors for depressive symptoms during pregnancy and depressive symptoms with postpartum onset.
Materials and methods Participants Pregnant women between 25 and 40 weeks of pregnancy were recruited at the offices of obstetrician/gynecologists affiliated with the McGill University Health Centre (MUHC) or at the
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ultrasound department at the Jewish General Hospital (JGH) in Montreal, Canada. Women were at least 18 years of age and able to communicate in French or English. The study was approved by the McGill University Faculty of Medicine Institutional Review Board and the participating institutions (MUHC and JGH). Procedure The procedure of this study, designed to assess post-traumatic stress symptoms related to childbirth, has been previously published [30]. Briefly, consenting participants were asked to complete the questionnaire battery and return them by mail at four different time points (third trimester, 1, 3 and 6 months postpartum). Data were collected from December 2005 to September 2009. The present study focused on data collected in the third trimester of pregnancy and at 3 months postpartum. Measures The Edinburgh Postnatal Depression Scale (EPDS) [25,26], a widely used 10-item measure of postpartum depressive symptoms, validated for use during pregnancy and the postpartum period, was used to assess depressive symptomatology. Items inquire about the mother’s mood in the past 7 days. Somatic symptoms likely to occur during this period are not included. Total scores range from 0 to 30, with scores 49 indicating ‘‘possible depression’’ and scores412 indicating ‘‘probable depression’’ [31]. Importantly, even minor depression during pregnancy and/or the postpartum period has been associated with negative maternal and infant outcomes [32–34]. We were interested in examining elevated depressed mood including subclinical or minor depression, therefore a cutoff score of 10 was selected to be indicative of elevated depressive symptoms. This threshold has been shown to have a sensitivity of 84–100% and a specificity of 76–88% when compared to a diagnosis of minor or major depression using a psychiatric interview such as the Structured Clinical Interview for DSM-III-R (SCID) [35–37]. The Trauma History Questionnaire (THQ) [38] consists of 24 items addressing a range of potentially traumatizing events in three areas: crime-related, general disaster and trauma and unwanted physical and sexual experiences. The THQ has been shown to have good stability over a 2- to 3-month period for reporting of most events. This measure was administered at study entry. The State Anxiety Inventory (STAI-S) [39] was used to measure anxiety symptoms. The STAI-S is comprised of 20 items, each rated 1–4, with the total score ranging from 20 to 80. A higher score indicates more anxiety symptoms. Internal consistency coefficients have been shown to be 0.81 for the STAI-state. The Anxiety Sensitivity Index (ASI) [40] is a 16-item questionnaire assessing fear of anxiety-related sensations. Scores are summed to provide a total score from 0 to 64, with higher scores on the ASI indicating greater levels of anxiety sensitivity. This scale has been shown to have good psychometric properties [41]. The ASI was completed at study entry. The Life Stress Event Scale (modified version) [42] lists 10 major life events that could have occurred in the past
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6 months. This questionnaire shows good internal consistency (Cronbach alpha ¼ 0.87). This scale was completed at study entry. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) [43]: Version A was administered in the third trimester and Version B was administered 1 month after childbirth. Version A is a 33-item measure assessing a woman’s fears about childbirth. Version B mirrors version A but is designed to assess women’s actual birth experience in relation to their expectations. The sum score for each version can range from a minimum score of 0 to a maximum score of 165. A difference score was calculated between the two versions. Thus, negative scores represented an experience that was more negative than expectations and positive scores reflected a more positive experience. This scale has been shown to have good psychometric properties [43,44]. The Parent Expectations Survey (PES) [45] version A was used to measure self-efficacy in expectant mothers. This 25item instrument assesses the mother’s confidence in relation to tasks she will perform in caring for her baby and her role as a parent, with higher scores reflecting higher self-efficacy. Initial studies suggest adequate psychometric properties [45,46]. The PES was completed at study entry. The MOS Social Support Survey (MOS-SSS) [47] was administered at each time point. This 7-item scale measures perceived support from one’s social network, with scores ranging from 6 to 28. This measure shows good internal consistency (Cronbach alpha ¼ 0.88). In this study, the sum scores were severely negatively skewed and no transformation resulted in a normal score distribution. The variable was thus dichotomized into two groups: a group with social support almost always available versus not. The Antenatal Questionnaire inquired about demographics, medical and obstetrical history, history of psychological difficulties and current health status and pregnancy complications. Information about labor and delivery complications, and mode of delivery were also obtained by telephone interview at 4–6 weeks postpartum. Statistical analyses Descriptive statistics (means, standard deviations, proportions, skewness and kurtosis) were calculated for all the variables. A cutoff score of 10 and above on the EPDS was used to classify women with depressive mood status during pregnancy. This cutoff point was chosen to include women with symptoms suggestive of minor depression. Correlation analysis was performed in order to examine the relationships between depressive symptoms (during pregnancy and postpartum) and sociodemographic and psychosocial variables. Two hierarchical multiple linear regression analyses were computed to identify antenatal psychosocial factors associated with prepartum and postpartum depressive symptoms, with EPDS scores as the dependent variable). For the postpartum model, women with depressed mood during pregnancy (EPDS 10) were removed from the postpartum analyses to focus specifically on new cases of elevated postpartum depressed mood. The pattern of correlations among the potential predictor variables was examined to determine the extent of multicollinearity. Sociodemographic and obstetrical
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variables were entered in the first block in each model (with the EPDS score during pregnancy for the second model) to determine the contribution of antenatal psychosocial variables over and above possible confounding factors. Statistical analyses were performed using the SPSS statistical software, version 18.0 (Chicago, IL).
Results Sample characteristics Of the 574 participants who agreed to participate in this study, 367 (64%) returned their self-report questionnaires. Three participants were excluded from the analyses because they had incomplete data. The characteristics of the 364 participants included in the final study sample are shown in Table 1. The mean age of the sample was 32.10 years (SD ¼ 4.49) and the mean years of school completed was 15.96 (SD ¼ 2.22). Sixteen percent (n ¼ 59) of the women reported a sexual trauma history, and 25.5% (n ¼ 93) a history of emotional difficulties (e.g. depression and anxiety). In terms of pregnancy complications, 21.4% (n ¼ 78) reported at least one complication (e.g. gestational hypertension and gestational diabetes). Of the 364 participants who completed the prepartum questionnaires, 226 (62.1%) returned their completed questionnaires at 3 months postpartum (Figure 1). Non-responders at 3 months postpartum were more likely to be single (Fisher, p ¼ 0.012), and to belong to a non-Caucasian ethnic group, 2(1, N ¼ 360) ¼ 10.88, p ¼ 0.001, compared to women who completed the postpartum questionnaires. Non-responders at the postpartum assessment did not differ on the psychosocial variables assessed in the prepartum.
Table 1. Demographic, obstetrical and psychosocial characteristics at study entry.
Age (years) Education (years) Household income $40 000/year (CAD) $41 000–$60 000/year (CAD) $61 000–$100 000/year (CAD) 4$101 000/year (CAD) Marital status Married/cohabiting (n) Ethnic group Caucasian Parity Primiparous (n) Gestational weeks Pregnancy complications (n) Past professional help (n) Sexual trauma history (n) State anxiety ASI Life stress MOS-SSS WDEQ PES
Mean
(SD)/%
32.10 15.96
(4.49) (2.22)
18.6% 23.0% 28.8% 29.7%
(64) (79) (99) (102)
96.7%
(352)
76.4%
(275)
46.2% 32.61 21.4% 25.5% 16.3% 34.93 13.37 3.63 22.88 54.10 8.13
(168) (3.18) (78) (93) (59) (10.03) (9.31) (4.34) (5.07) (20.10) (1.19)
ASI, Anxiety Sensitivity Scale; MOS-SSS, MOS Social Support Survey; WDEQ, Delivery Expectancy/Experience Questionnaire; PES, Parent Expectations Survey; CAD, Canadian dollars.
DOI: 10.3109/0167482X.2014.947953
Factors associated with depressive symptoms during pregnancy and with postpartum onset
Figure 1. Study flowchart.
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Consented to participate (n = 574)
Numbers participating at baseline data collection (n = 364)
Losses after consent n = 210 Reasons (n): No longer interested and/or no time (15); Delivered (19); Felt too ill (3); Misplaced the questionnaires (7); Never responded to reminder phone calls (163); Incomplete data (3)
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Losses to follow-up n = 138
Numbers participating at 3 months postpartum data collection: (n = 226)
Among women completing the postpartum questionnaires (n ¼ 226), 8% (n ¼ 18) reported at least one complication (i.e. use of forceps or vacuum), and 30.5% (n ¼ 69) reported having a cesarean section.
Table 2. Correlates of depressive symptoms during pregnancy and the postpartum period.
Rates of depressed mood
Variables
In pregnancy, 28.3% (n ¼ 103/364) of women obtained a score of 10 on the EPDS. At 3 months postpartum, 16.4% (n ¼ 37/226) of women obtained a score of 10 on the EPDS. Among them, 6.6% (n ¼ 15/226) were new postpartum cases of depressed mood and 9.7% (n ¼ 22/226) had already been depressed in pregnancy (EPDS 10). Among women who did not report elevated depressive symptoms in the prepartum (163/226), 9.2% (15/163) were new onset cases of depressive symptoms in the postpartum. Among women who were depressed in the prepartum (63/ 226), 34.9% (22/63) continued to report elevated symptoms at the 3-month postpartum assessment. Overall, among women who completed both the pre- and postpartum questionnaires (n ¼ 226), the mean EPDS score decreased significantly from pre- (mean ¼ 6.88, SD ¼ 4.30) to postpartum (mean ¼ 5.26, SD ¼ 4.58), paired t(225) ¼ 5.85, p50.001.
Age Marital statusa Income Ethnic group Parity Pregnancy Comp. Past professional help Sexual trauma history ASI State-Anxiety WDEQ Social support Life events PES EPDS (3rd trimester) Delivery complications Delivery mode
Correlates of depressive symptoms The relationships between sociodemographics, psychosocial variables and depressive symptoms during pregnancy and the postpartum period for women are displayed in Table 2. Women with elevated prepartum EPDS scores (prepartum EPDS score 10, n ¼ 63) were removed from the postpartum analysis in order to identify factors uniquely associated with elevated depressed mood in women without elevated prepartum depressive symptoms (prepartum EPDS score510). Elevated depressive symptoms during pregnancy was associated with the following variables: being single, belonging to a non-Caucasian ethnic group, lower household income, having sought professional help in the past, a history of sexual trauma, higher anxiety sensitivity, higher state anxiety, greater fear of childbirth, lower social support,
Prenatal EPDS (n ¼ 364) 0.09 0.17*** 0.17*** 0.12* 0.005 0.05 0.17** 0.15** 0.43*** 0.61*** 0.39*** 0.32*** 0.25*** 0.27**
Postpartum EPDS Non-depressed prepartum women (n ¼ 163) 0.09 – 0.05 0.03 0.14 0.10 0.28*** 0.10 0.20* 0.34** 0.24** 0.22** 0.05 0.26** 0.29*** 0.12 0.04
a
All non-depressed prepartum participants who completed the postpartum questionnaires (n ¼ 163) were married/co-habiting. *p50.05; **p50.01; ***p50.001.
reporting at least 1 stressful event in the past 6 months and lower parental self-efficacy. Having sought profession help in the past, higher anxiety sensitivity, higher state-anxiety during pregnancy, greater fear of childbirth, lower social support, lower parental selfefficacy and higher depressed mood scores during pregnancy were associated with elevated postpartum depressive symptoms in women without elevated prepartum depressive symptoms. Sociodemographics, parity, pregnancy and delivery complications were not associated with depressive symptoms in the postpartum period. Predictors of depressed mood Two hierarchical multiple regression analyses were computed to determine the role of antenatal psychosocial factors
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Table 3. Predictors of elevated depressive symptoms during pregnancy (n ¼ 364).
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Predictors Step 1 Age Marital status Income Ethnicity Step 2 Age Marital status Income Ethnicity Past professional help Sexual trauma history WDEQ ASI State anxiety PES Social support Life events Total R2 ¼ 0.47
DR2
b
0.05** 0.05 0.13* 0.11* 0.06 0.42*** 0.04 0.05 0.05 0.09* 0.09* 0.09* 0.04 0.20*** 0.43*** 0.04 0.05 0.11**
*p50.05; **p50.01; ***p50.001. Table 4. Predictors of elevated postpartum depressive symptoms in women without prepartum depressed mood. Predictors Step 1 Prepartum EPDS Step 2 Prepartum EPDS Past professional help ASI State-anxiety PES Social support WDEQ Total R2 ¼ 0.27***
DR2
b
0.08*** 0.29*** 0.19*** 0.16* 0.24** 0.03 0.14 0.13 0.15* 0.20**
*p50.05; **p50.01; ***p50.001.
in predicting depression during pregnancy and the postpartum after controlling for sociodemographic and obstetrical factors. In the first step, demographic and obstetrical factors identified to be significant in the correlational analyses were entered, followed by the psychosocial factors in the final. As shown in Table 3, belonging to a non-Caucasian ethnic group, having past emotional difficulties, a history of sexual trauma, higher anxiety sensitivity, higher state anxiety and having experienced at least one stressful live event in the previous 6 months were significant factors contributing to elevated depressive symptoms in the third trimester of pregnancy. The final model explained 47% of the variance in third trimester depressive symptoms. In women who did not experience elevated depressed mood prepartum, higher depressed mood scores during pregnancy, past emotional difficulties, lower social support during pregnancy and a more negative childbirth experience were associated with higher postpartum depressive symptoms. The final model shown in Table 4 explained 27% of the variance in postpartum depressive symptoms.
Discussion In the present study, the rate of depressed mood was higher during pregnancy compared to the postpartum screening. The rate of depressed mood was 28.3% during the third trimester of pregnancy and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new postpartum cases. The studies which used the same cutoff score as the current study (10 on EPDS) obtained lower rates in pregnancy (17–21.9%) but similar rates postpartum (13–16.8%) [10,22,48]. A study by Andersson et al. [21] reported similar rates during pregnancy and postpartum, but this team evaluated the prevalence of depression and/or anxiety using the PRIME-MD (29.2% during pregnancy and 16.5% in the postpartum period). Given the high comorbidity of symptoms of anxiety and depression in this population, it is not surprising that the rates would be similar, since the EPDS takes into account symptoms of anxiety. The rate of new onset postpartum depressive symptoms in our study is similar to a recent study conducted in USA which reported a rate of new onset postpartum depression of 6% in women at 4–12 weeks following childbirth [13]. While more than half of women reporting elevated depressive symptoms postpartum exhibit elevated symptoms during pregnancy, for a subgroup of women, symptoms only intensify postpartum which underscores the importance of systematically screening both during pregnancy and in the postpartum period. In terms of the course of depressive symptoms, we observed significant reductions in the intensity of depressive symptoms from pregnancy to postpartum in women who completed the postnatal follow-up. This decrease in depressive symptoms from pregnancy to postpartum has also been found in other studies [7,11,13,17]. However, it is difficult to generalize this finding to single women or those of ethnic minority groups, as they were proportionally underrepresented among those who responded in the postnatal period. In the present study, belonging to a non-Caucasian ethnic group, a history of emotional problems or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and having experienced stressful life events were associated with depressed mood during pregnancy. These results are largely consistent with those obtained from other studies on prenatal depression risk factors [18,19,29]. However, some of the factors identified in the present study have received little empirical attention, most notably anxiety sensitivity. To our knowledge, no prior study to date has examined the association between anxiety sensitivity and prenatal depression. However, it has been previously associated with postnatal depression [49]. In other populations, anxiety sensitivity has been examined as a predisposing factor for depression, in particular as a component of fear of cognitive dyscontrol [50–52]. Further research is needed to better understand the relationship between anxiety sensitivity and prenatal depression. A history of sexual abuse was also identified as a predictor of depressed mood during pregnancy, which is consistent with findings of a recent study [53]. It is likely that pregnancy and its implications (e.g. vaginal examinations, bodily changes and feelings of losing control over one’s body) may reactivate
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DOI: 10.3109/0167482X.2014.947953
Factors associated with depressive symptoms during pregnancy and with postpartum onset
painful memories in women who were victims of sexual abuse [54–56]. It is common to observe an increase in symptoms of anxiety and depression during this period, as well as a tendency to avoid prenatal care. It is clear that women with a history of sexual abuse have specific needs for follow-up care. Four risk factors emerged as predictors of depressive symptoms with postpartum onset: higher depressive symptomatology during pregnancy, a history of emotional problems, a delivery that was more difficult than expected and a lower social support during pregnancy. Some of these factors have been widely established in the literature as putting women at risk for PPD, such as prenatal depression and a history of depression [28,57–59]. However, these studies have not always distinguished between postpartum depression that continues from pregnancy and depression with postpartum onset of symptoms. These findings confirm that even among women not experiencing elevated depression during pregnancy (EPDS 10), higher scores below the cutoff range on the EPDS may place women at higher risk postpartum. Childbirth fear when measured in the prenatal period has previously been associated with PPD [60]. In our study, having experienced a more difficult childbirth than expected was independently associated with elevated depressive symptoms in women without prepartum depressed mood. An incongruence between maternal expectations and the actual experience, in addition to feelings of loss, are themes often found in women with PPD [61]. Our findings suggest that a more negative childbirth experience than initially expected may also contribute to the development of new onset postpartum depression. Lower perceived social support during pregnancy was associated with elevated postpartum depressive symptoms in women without prepartum depressed mood. Social support during pregnancy has previously been shown to be associated with postpartum depression [28,57]. While the study conducted by Sidebottom et al. [13] did not find social support to be associated with postpartum onset of depressive symptoms, lack of phone access, which is likely a proxy for extreme poverty and/or social isolation, was significantly associated with postpartum onset of depressive symptoms. Our findings suggest that even among women who are not exhibiting elevated levels of depressed mood during pregnancy, lower perceived social support during pregnancy places these women at greater risk of elevated postpartum depressive symptoms. Our study has several limitations, including its observational design, which precludes any definitive conclusions about the direction of a cause-and-effect relationship. The women in this sample are more educated and have a higher income relative to the Canadian population. Also, single women were under-represented. Thus, the sample may not generalize to all women giving birth in Canada. Cases of depressed mood during pregnancy and the postpartum period were identified using a self-report questionnaire, which is not equivalent to a diagnosis established on the basis of a semistructured interview. Thus, in this study, we refer to the probability of a diagnosis of depression with the term elevated depressive symptoms. We do not know whether depressed mood was present prior to pregnancy and for how long, or whether onset was actually during pregnancy. Finally, there
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may have been a negative response bias in the questionnaires assessing risk factors for women concurrently experiencing depressed mood. Certain risk factors during pregnancy, such as depressed mood and history of emotional difficulties, can help identify women who are at risk of developing PPD. In these cases, a more tailored follow-up could be implemented. For example, Zlotnick et al. [62] found in a pilot study that an interpersonally-oriented group intervention during pregnancy was efficacious in women at high-risk in preventing PPD. Considering the possible consequences of perinatal depression on both mother and infant, interventions should occur as early as possible. Furthermore, the length of delay to adequate treatment is a significant factor in the duration of PPD [27]. Strategies to improve social support during pregnancy, including telephone and online communication [63,64], may also help women to feel more supported during pregnancy and the postpartum period. It may also be important to consider women’s expectations, fears and experiences of childbirth. Finally, certain forms of psychotherapy (e.g. cognitive-behavioural therapy and interpersonal therapy) have been found to be more effective than routine medical care in treating PPD [65]. These treatment options should be considered for women experiencing PPD.
Acknowledgements We thank all the women who took the time to participate in this study.
Declaration of interest None of the authors has a conflict of interest to declare. This study was funded by an operating grant from the Canadian Institutes of Health Research (CIHR) (25933). N.V. was a recipient of a doctoral scholarship from the Social Sciences and Humanities Research Council of Canada (SSHRC) (7522007-1936) and the Fonds que´be´cois de la recherche sur la socie´te´ et la culture (105861).
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33. Setse R, Grogan R, Pham L, et al. Longitudinal study of depressive symptoms and health-related quality of life during pregnancy and after delivery: the Health Status in Pregnancy (HIP) study. Matern Child Health J 2009;13:577–87. 34. Deave T, Heron J, Evans J, Emond A. The impact of maternal depression in pregnancy on early child development. BJOG 2008; 115:1043–51. 35. Harris B, Huckle P, Thomas R, et al. The use of rating scales to identify post-natal depression. Br J Psychiatry 1989;154:813–7. 36. Murray L, Carothers AD. The validation of the Edinburgh Postnatal Depression Scale on a community sample. Br J Psychiatry 1990;157:288–90. 37. Zelkowitz P, Milet TH. Screening for post-partum depression in a community sample. Can J Psychiatry 1995;40:80–6. 38. Green BL. Psychometric review of Trauma History Questionnaire (Self-report). In: Stamm BH, Varra EM, eds. Meaurement of stress, trauma and adaptation. Lutherville, MD: Sidran; 1996. 39. Spielberger CD, Gorsuch RL, Lushene RE. Manual for the StateTrait Anxiety Inventory. Alto, CA: Consulting Psychologist Press; 1983. 40. Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther 1986;24:1–8. 41. Peterson R, Reiss S. Anxiety Sensitivity Index Revised test manual. Worthington, OH: International Diagnostic Systems Publishing Corporation; 1992. 42. Hurst MW, Jenkins CD, Rose RM. The assessment of life change stress: a comparative and methodological inquiry. Psychosom Med 1978;40:126–41. 43. Wijma K, Wijma B, Zar M. Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. J Psychosom Obstet Gynaecol 1998;19:84–97. 44. Soet JE, Brack GA, DiIorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth 2003;30:36–46. 45. Reece SM. The parent expectations survey: a measure of perceived self-efficacy. Clin Nurs Res 1992;1:336–46. 46. McCarter-Spaulding DE, Kearney MH. Parenting self-efficacy and perception of insufficient breast milk. J Obstet Gynecol Neonatal Nurs 2001;30:515–22. 47. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32:705–14. 48. Josefsson A, Berg G, Nordin C, Sydsjo G. Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 2001;80:251–5. 49. Fairbrother N, Woody SR. Fear of childbirth and obstetrical events as predictors of postnatal symptoms of depression and posttraumatic stress disorder. J Psychosom Obstet Gynaecol 2007;28: 239–42. 50. Cox BJ, Enns MW, Freeman P, Walker JR. Anxiety sensitivity and major depression: examination of affective state dependence. Behav Res Ther 2001;39:1349–56. 51. Rector NA, Szacun-Shimizu K, Leybman M. Anxiety sensitivity within the anxiety disorders: disorder-specific sensitivities and depression comorbidity. Behav Res Ther 2007;45: 1967–75. 52. Taylor S, Koch WJ, Woody S, McLean P. Anxiety sensitivity and depression: how are they related? J Abnorm Psychol 1996;105: 474–9. 53. Rich-Edwards JW, James-Todd T, Mohllajee A, et al. Lifetime maternal experiences of abuse and risk of pre-natal depression in two demographically distinct populations in Boston. Int J Epidemiol 2011;40:375–84. 54. Courtois CA, Courtois RC. Pregnancy and childbirth as triggers for abuse memories: implications for care. Birth 1992;19:222–3. 55. Leeners B, Richter-Appelt H, Imthurn B, Rath W. Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women. J Psychosom Res 2006;61: 139–51. 56. Seng JS, Hassinger JA. Relationship strategies and interdisciplinary collaboration. Improving maternity care with survivors of childhood sexual abuse. J Nurse Midwifery 1998;43:287–95. 57. Milgrom J, Gemmill AW, Bilszta JL, et al. Antenatal risk factors for postnatal depression: a large prospective study. J Affect Disord 2008;108:147–57.
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58. O’Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol 2013; 9:379–407. 59. Davey HL, Tough SC, Adair CE, Benzies KM. Risk factors for subclinical and major postpartum depression among a community cohort of Canadian women. Matern Child Health J 2011;15: 866–75. 60. Soderquist J, Wijma B, Thorbert G, Wijma K. Risk factors in pregnancy for post-traumatic stress and depression after childbirth. BJOG 2009;116:672–80. 61. Beck CT. Postpartum depression: a metasynthesis. Qual Health Res 2002;12:453–72.
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62. Zlotnick C, Johnson SL, Miller IW, et al. Postpartum depression in women receiving public assistance: pilot study of an interpersonaltherapy-oriented group intervention. Am J Psychiatry 2001;158: 638–40. 63. Dennis CL, Kingston D. A systematic review of telephone support for women during pregnancy and the early postpartum period. J Obstet Gynecol Neonatal Nurs 2008;37:301–14. 64. Evans M, Donelle L, Hume-Loveland L. Social support and online postpartum depression discussion groups: a content analysis. Patient Educ Couns 2012;87:405–10. 65. O’Hara MW. Postpartum depression: what we know. J Clin Psychol 2009;65:1258–69.
ä Current knowledge on this subject Depressive symptoms during pregnancy and the postpartum period are common, under-recognized and poorly treated. Specific demographic, clinical and psychosocial variables have been differentially associated with depressive symptoms during pregnancy and postpartum depression. However, few studies have evaluated risk factors associated with depressive symptoms with onset in the postpartum period. ä What this study adds The rate of depressed mood during pregnancy was 28.3%, and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new cases with onset in the postpartum period. Multiple regression analysis showed that belonging to a non-Caucasian ethnic group, a history of emotional problems or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and experiencing stressful life events were associated with depressed mood during pregnancy. Predictors of depressive symptoms with postpartum onset included lower perceived social support during pregnancy and a delivery that was more difficult than expected. These findings may help to identify and better tailor interventions for women at risk of depression during pregnancy and the postpartum.
ORIGINAL ARTICLE
Rates and risk factors associated with depressive symptoms during pregnancy and with postpartum onset J Psychosom Obstet Gynaecol 2014.35:84-91. Downloaded from informahealthcare.com by Kainan University on 04/06/15. For personal use only.
Nancy Verreault1,2, Deborah Da Costa1,3, Andre´ Marchand2, Kierla Ireland1, Maria Dritsa1, and Samir Khalife´4 1
Division of Clinical Epidemiology, McGill University Health Centre, Montre´al, QC, Canada, 2Department of Psychology, Universite´ du Que´bec a` Montre´al, Montre´al, QC, Canada, 3Department of Medicine, McGill University, Montre´al, QC, Canada, and 4Department of Obstetrics and Gynecology, Jewish General Hospital, Montre´al, QC, Canada Abstract
Keywords
The objectives of this study were to evaluate the prevalence of depressive symptoms in the third trimester of pregnancy and at 3 months postpartum and to prospectively identify risk factors associated with elevated depressive symptoms during pregnancy and with postpartum onset. About 364 women attending antenatal clinics or at the time of their ultrasound were recruited and completed questionnaires in pregnancy and 226 returned their questionnaires at 3 months postpartum. Depressed mood was assessed by the Edinburgh Postnatal Depression Scale (EPDS; score of 10). The rate of depressed mood during pregnancy was 28.3% and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new postpartum cases. In the present study, belonging to a non-Caucasian ethnic group, a history of emotional problems (e.g. anxiety and depression) or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and having experienced stressful events were associated with elevated depressed mood during pregnancy. Four risk factors emerged as predictors of new onset elevated depressed mood at 3 months postpartum: higher depressive symptomatology during pregnancy, a history of emotional problems, lower social support during pregnancy and a delivery that was more difficult than expected. The importance of identifying women at risk of depressed mood early in pregnancy and clinical implications are discussed.
Depressed mood, perinatal period, prevalence, risk factors
Introduction Depression during pregnancy is common, affecting 8.5–11% of women [1,2]. With respect to the postpartum period, a meta-analysis by O’Hara and Swain [3] found an average prevalence rate of 13%, while a more recent meta-analysis by Gavin et al. [1] reported rates of minor or major depression in the range of 6.5–12.9% over the first year postpartum. The consequences of perinatal depression on both mother and infant are significant and have been well documented [4–6]. Most prospective studies examining both pre- and postnatal depression have found that depressive symptoms are more prevalent or more severe during pregnancy compared to the postpartum period [7–13]. A few studies also suggest that depression during pregnancy tends to persist into the postpartum with about half of postpartum depression cases continuing from pregnancy [11,13,14]. The prevalence of depression with postpartum onset has been found to be between 3.4% and 8.6% [8,11,13–18]. The difference in rates Address for correspondence: Nancy Verreault, Division of Clinical Epidemiology, McGill University Health Centre, 687 Pine Avenue West, Montreal, QC H3A 1A2, Canada. Tel: +514 934 1934 ext: 44723. Fax: +514 934 8293. Email: [email protected]
History Received 11 November 2013 Revised 16 July 2014 Accepted 21 July 2014
of postpartum depression (PPD) observed across studies with varying methodology highlights the importance of prospectively studying the course of depression and associated risk factors at different times over the perinatal period. Lancaster et al. [19] conducted a literature review examining risk factors associated with prenatal depression. Among these risk factors, the presence of co-morbid anxiety, stressful life events, domestic violence, relationship difficulties, poor social support, a history of depression and unplanned pregnancy were most strongly associated with depression during pregnancy. Other factors such as younger age [2], foreign citizenship or membership in a specific ethnic/racial group [2,18,20,21], low self-esteem [22], a negative cognitive style [22], a history of abuse [22,23], chronic health problems [2], and obstetric complications [24] have also been found to be related to prenatal depression. Factors related to marital and socioeconomic status have been found to be associated with both pre- and postnatal depression, but these results have been less consistent and have smaller effect sizes [21,25,26]. Risk factors associated with PPD are numerous and have been widely studied without always distinguishing between PPD depressive symptoms that are persistent or reoccur from
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DOI: 10.3109/0167482X.2014.947953
Factors associated with depressive symptoms during pregnancy and with postpartum onset
pregnancy compared to those with postpartum onset. Metaanalyses have been carried out to estimate the magnitude of the effect size for each risk factor [3,20,27,28]. Among the factors studied in relation to postpartum depression, a history of depression, prenatal depression and/or anxiety, stressful life events, poor social support, negative cognitive style, low selfesteem, lower marital satisfaction and higher childcare stress have been found to be most strongly associated with PPD (i.e. moderate to strong effect sizes) [27,28]. Despite the numerous risk factors that have emerged in the literature, very few studies have excluded women who were already experiencing prenatal depression from their analyses, thus incorporating a source of bias. Among studies that have specifically excluded women with prenatal depression, the following factors have been found to predict depression with postpartum onset: lower socioeconomic status [17,18], previous psychiatric problems, pre-pregnancy obesity, living alone [21], a more negative perception of parental care in one’s own childhood, having suffered stressful events [17], elevated prenatal depressive symptomatology [16], and using assisted reproductive technology [22]. A limited number of studies have compared risk factors for depression during pregnancy with risk factors for PPD [10,22–24,29]. Leigh and Milgrom [29] identified prenatal depression, a history of depression and a higher level of parental stress as risk factors specific to PPD. A study by Mora et al. [23] found comorbid mental health problems, having other children in the household and a lower educational level as factors specific to PPD, while ambivalence toward pregnancy was a risk factor for prenatal depression. In conclusion, very few studies have prospectively evaluated the prevalence of perinatal depression by distinguishing between the percentage of women experiencing elevated depressive symptoms during pregnancy from those who have depressive symptoms with onset in the postpartum period. Moreover, while some studies have evaluated risk factors for pre- or postnatal depression, very few have compared the risk factors specific to each stage. A better understanding of the risk factors associated with elevated depressive symptoms at each stage of the perinatal period would permit a more effective identification of at-risk women and the earlier development of tailored interventions. This study aimed to evaluate the prevalence of elevated depressive symptoms in the third trimester of pregnancy and at 3 months postpartum. We provide estimates of elevated postpartum depressive symptoms with postpartum onset and postpartum depression that persists or reoccurs from pregnancy. This study also sought to prospectively identify risk factors associated with elevated depressive symptoms in the third trimester of pregnancy and to new-onset postpartum depressive symptoms. We hypothesized that there are different risk factors for depressive symptoms during pregnancy and depressive symptoms with postpartum onset.
Materials and methods Participants Pregnant women between 25 and 40 weeks of pregnancy were recruited at the offices of obstetrician/gynecologists affiliated with the McGill University Health Centre (MUHC) or at the
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ultrasound department at the Jewish General Hospital (JGH) in Montreal, Canada. Women were at least 18 years of age and able to communicate in French or English. The study was approved by the McGill University Faculty of Medicine Institutional Review Board and the participating institutions (MUHC and JGH). Procedure The procedure of this study, designed to assess post-traumatic stress symptoms related to childbirth, has been previously published [30]. Briefly, consenting participants were asked to complete the questionnaire battery and return them by mail at four different time points (third trimester, 1, 3 and 6 months postpartum). Data were collected from December 2005 to September 2009. The present study focused on data collected in the third trimester of pregnancy and at 3 months postpartum. Measures The Edinburgh Postnatal Depression Scale (EPDS) [25,26], a widely used 10-item measure of postpartum depressive symptoms, validated for use during pregnancy and the postpartum period, was used to assess depressive symptomatology. Items inquire about the mother’s mood in the past 7 days. Somatic symptoms likely to occur during this period are not included. Total scores range from 0 to 30, with scores 49 indicating ‘‘possible depression’’ and scores412 indicating ‘‘probable depression’’ [31]. Importantly, even minor depression during pregnancy and/or the postpartum period has been associated with negative maternal and infant outcomes [32–34]. We were interested in examining elevated depressed mood including subclinical or minor depression, therefore a cutoff score of 10 was selected to be indicative of elevated depressive symptoms. This threshold has been shown to have a sensitivity of 84–100% and a specificity of 76–88% when compared to a diagnosis of minor or major depression using a psychiatric interview such as the Structured Clinical Interview for DSM-III-R (SCID) [35–37]. The Trauma History Questionnaire (THQ) [38] consists of 24 items addressing a range of potentially traumatizing events in three areas: crime-related, general disaster and trauma and unwanted physical and sexual experiences. The THQ has been shown to have good stability over a 2- to 3-month period for reporting of most events. This measure was administered at study entry. The State Anxiety Inventory (STAI-S) [39] was used to measure anxiety symptoms. The STAI-S is comprised of 20 items, each rated 1–4, with the total score ranging from 20 to 80. A higher score indicates more anxiety symptoms. Internal consistency coefficients have been shown to be 0.81 for the STAI-state. The Anxiety Sensitivity Index (ASI) [40] is a 16-item questionnaire assessing fear of anxiety-related sensations. Scores are summed to provide a total score from 0 to 64, with higher scores on the ASI indicating greater levels of anxiety sensitivity. This scale has been shown to have good psychometric properties [41]. The ASI was completed at study entry. The Life Stress Event Scale (modified version) [42] lists 10 major life events that could have occurred in the past
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6 months. This questionnaire shows good internal consistency (Cronbach alpha ¼ 0.87). This scale was completed at study entry. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) [43]: Version A was administered in the third trimester and Version B was administered 1 month after childbirth. Version A is a 33-item measure assessing a woman’s fears about childbirth. Version B mirrors version A but is designed to assess women’s actual birth experience in relation to their expectations. The sum score for each version can range from a minimum score of 0 to a maximum score of 165. A difference score was calculated between the two versions. Thus, negative scores represented an experience that was more negative than expectations and positive scores reflected a more positive experience. This scale has been shown to have good psychometric properties [43,44]. The Parent Expectations Survey (PES) [45] version A was used to measure self-efficacy in expectant mothers. This 25item instrument assesses the mother’s confidence in relation to tasks she will perform in caring for her baby and her role as a parent, with higher scores reflecting higher self-efficacy. Initial studies suggest adequate psychometric properties [45,46]. The PES was completed at study entry. The MOS Social Support Survey (MOS-SSS) [47] was administered at each time point. This 7-item scale measures perceived support from one’s social network, with scores ranging from 6 to 28. This measure shows good internal consistency (Cronbach alpha ¼ 0.88). In this study, the sum scores were severely negatively skewed and no transformation resulted in a normal score distribution. The variable was thus dichotomized into two groups: a group with social support almost always available versus not. The Antenatal Questionnaire inquired about demographics, medical and obstetrical history, history of psychological difficulties and current health status and pregnancy complications. Information about labor and delivery complications, and mode of delivery were also obtained by telephone interview at 4–6 weeks postpartum. Statistical analyses Descriptive statistics (means, standard deviations, proportions, skewness and kurtosis) were calculated for all the variables. A cutoff score of 10 and above on the EPDS was used to classify women with depressive mood status during pregnancy. This cutoff point was chosen to include women with symptoms suggestive of minor depression. Correlation analysis was performed in order to examine the relationships between depressive symptoms (during pregnancy and postpartum) and sociodemographic and psychosocial variables. Two hierarchical multiple linear regression analyses were computed to identify antenatal psychosocial factors associated with prepartum and postpartum depressive symptoms, with EPDS scores as the dependent variable). For the postpartum model, women with depressed mood during pregnancy (EPDS 10) were removed from the postpartum analyses to focus specifically on new cases of elevated postpartum depressed mood. The pattern of correlations among the potential predictor variables was examined to determine the extent of multicollinearity. Sociodemographic and obstetrical
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variables were entered in the first block in each model (with the EPDS score during pregnancy for the second model) to determine the contribution of antenatal psychosocial variables over and above possible confounding factors. Statistical analyses were performed using the SPSS statistical software, version 18.0 (Chicago, IL).
Results Sample characteristics Of the 574 participants who agreed to participate in this study, 367 (64%) returned their self-report questionnaires. Three participants were excluded from the analyses because they had incomplete data. The characteristics of the 364 participants included in the final study sample are shown in Table 1. The mean age of the sample was 32.10 years (SD ¼ 4.49) and the mean years of school completed was 15.96 (SD ¼ 2.22). Sixteen percent (n ¼ 59) of the women reported a sexual trauma history, and 25.5% (n ¼ 93) a history of emotional difficulties (e.g. depression and anxiety). In terms of pregnancy complications, 21.4% (n ¼ 78) reported at least one complication (e.g. gestational hypertension and gestational diabetes). Of the 364 participants who completed the prepartum questionnaires, 226 (62.1%) returned their completed questionnaires at 3 months postpartum (Figure 1). Non-responders at 3 months postpartum were more likely to be single (Fisher, p ¼ 0.012), and to belong to a non-Caucasian ethnic group, 2(1, N ¼ 360) ¼ 10.88, p ¼ 0.001, compared to women who completed the postpartum questionnaires. Non-responders at the postpartum assessment did not differ on the psychosocial variables assessed in the prepartum.
Table 1. Demographic, obstetrical and psychosocial characteristics at study entry.
Age (years) Education (years) Household income $40 000/year (CAD) $41 000–$60 000/year (CAD) $61 000–$100 000/year (CAD) 4$101 000/year (CAD) Marital status Married/cohabiting (n) Ethnic group Caucasian Parity Primiparous (n) Gestational weeks Pregnancy complications (n) Past professional help (n) Sexual trauma history (n) State anxiety ASI Life stress MOS-SSS WDEQ PES
Mean
(SD)/%
32.10 15.96
(4.49) (2.22)
18.6% 23.0% 28.8% 29.7%
(64) (79) (99) (102)
96.7%
(352)
76.4%
(275)
46.2% 32.61 21.4% 25.5% 16.3% 34.93 13.37 3.63 22.88 54.10 8.13
(168) (3.18) (78) (93) (59) (10.03) (9.31) (4.34) (5.07) (20.10) (1.19)
ASI, Anxiety Sensitivity Scale; MOS-SSS, MOS Social Support Survey; WDEQ, Delivery Expectancy/Experience Questionnaire; PES, Parent Expectations Survey; CAD, Canadian dollars.
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Factors associated with depressive symptoms during pregnancy and with postpartum onset
Figure 1. Study flowchart.
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Consented to participate (n = 574)
Numbers participating at baseline data collection (n = 364)
Losses after consent n = 210 Reasons (n): No longer interested and/or no time (15); Delivered (19); Felt too ill (3); Misplaced the questionnaires (7); Never responded to reminder phone calls (163); Incomplete data (3)
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Losses to follow-up n = 138
Numbers participating at 3 months postpartum data collection: (n = 226)
Among women completing the postpartum questionnaires (n ¼ 226), 8% (n ¼ 18) reported at least one complication (i.e. use of forceps or vacuum), and 30.5% (n ¼ 69) reported having a cesarean section.
Table 2. Correlates of depressive symptoms during pregnancy and the postpartum period.
Rates of depressed mood
Variables
In pregnancy, 28.3% (n ¼ 103/364) of women obtained a score of 10 on the EPDS. At 3 months postpartum, 16.4% (n ¼ 37/226) of women obtained a score of 10 on the EPDS. Among them, 6.6% (n ¼ 15/226) were new postpartum cases of depressed mood and 9.7% (n ¼ 22/226) had already been depressed in pregnancy (EPDS 10). Among women who did not report elevated depressive symptoms in the prepartum (163/226), 9.2% (15/163) were new onset cases of depressive symptoms in the postpartum. Among women who were depressed in the prepartum (63/ 226), 34.9% (22/63) continued to report elevated symptoms at the 3-month postpartum assessment. Overall, among women who completed both the pre- and postpartum questionnaires (n ¼ 226), the mean EPDS score decreased significantly from pre- (mean ¼ 6.88, SD ¼ 4.30) to postpartum (mean ¼ 5.26, SD ¼ 4.58), paired t(225) ¼ 5.85, p50.001.
Age Marital statusa Income Ethnic group Parity Pregnancy Comp. Past professional help Sexual trauma history ASI State-Anxiety WDEQ Social support Life events PES EPDS (3rd trimester) Delivery complications Delivery mode
Correlates of depressive symptoms The relationships between sociodemographics, psychosocial variables and depressive symptoms during pregnancy and the postpartum period for women are displayed in Table 2. Women with elevated prepartum EPDS scores (prepartum EPDS score 10, n ¼ 63) were removed from the postpartum analysis in order to identify factors uniquely associated with elevated depressed mood in women without elevated prepartum depressive symptoms (prepartum EPDS score510). Elevated depressive symptoms during pregnancy was associated with the following variables: being single, belonging to a non-Caucasian ethnic group, lower household income, having sought professional help in the past, a history of sexual trauma, higher anxiety sensitivity, higher state anxiety, greater fear of childbirth, lower social support,
Prenatal EPDS (n ¼ 364) 0.09 0.17*** 0.17*** 0.12* 0.005 0.05 0.17** 0.15** 0.43*** 0.61*** 0.39*** 0.32*** 0.25*** 0.27**
Postpartum EPDS Non-depressed prepartum women (n ¼ 163) 0.09 – 0.05 0.03 0.14 0.10 0.28*** 0.10 0.20* 0.34** 0.24** 0.22** 0.05 0.26** 0.29*** 0.12 0.04
a
All non-depressed prepartum participants who completed the postpartum questionnaires (n ¼ 163) were married/co-habiting. *p50.05; **p50.01; ***p50.001.
reporting at least 1 stressful event in the past 6 months and lower parental self-efficacy. Having sought profession help in the past, higher anxiety sensitivity, higher state-anxiety during pregnancy, greater fear of childbirth, lower social support, lower parental selfefficacy and higher depressed mood scores during pregnancy were associated with elevated postpartum depressive symptoms in women without elevated prepartum depressive symptoms. Sociodemographics, parity, pregnancy and delivery complications were not associated with depressive symptoms in the postpartum period. Predictors of depressed mood Two hierarchical multiple regression analyses were computed to determine the role of antenatal psychosocial factors
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Table 3. Predictors of elevated depressive symptoms during pregnancy (n ¼ 364).
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Predictors Step 1 Age Marital status Income Ethnicity Step 2 Age Marital status Income Ethnicity Past professional help Sexual trauma history WDEQ ASI State anxiety PES Social support Life events Total R2 ¼ 0.47
DR2
b
0.05** 0.05 0.13* 0.11* 0.06 0.42*** 0.04 0.05 0.05 0.09* 0.09* 0.09* 0.04 0.20*** 0.43*** 0.04 0.05 0.11**
*p50.05; **p50.01; ***p50.001. Table 4. Predictors of elevated postpartum depressive symptoms in women without prepartum depressed mood. Predictors Step 1 Prepartum EPDS Step 2 Prepartum EPDS Past professional help ASI State-anxiety PES Social support WDEQ Total R2 ¼ 0.27***
DR2
b
0.08*** 0.29*** 0.19*** 0.16* 0.24** 0.03 0.14 0.13 0.15* 0.20**
*p50.05; **p50.01; ***p50.001.
in predicting depression during pregnancy and the postpartum after controlling for sociodemographic and obstetrical factors. In the first step, demographic and obstetrical factors identified to be significant in the correlational analyses were entered, followed by the psychosocial factors in the final. As shown in Table 3, belonging to a non-Caucasian ethnic group, having past emotional difficulties, a history of sexual trauma, higher anxiety sensitivity, higher state anxiety and having experienced at least one stressful live event in the previous 6 months were significant factors contributing to elevated depressive symptoms in the third trimester of pregnancy. The final model explained 47% of the variance in third trimester depressive symptoms. In women who did not experience elevated depressed mood prepartum, higher depressed mood scores during pregnancy, past emotional difficulties, lower social support during pregnancy and a more negative childbirth experience were associated with higher postpartum depressive symptoms. The final model shown in Table 4 explained 27% of the variance in postpartum depressive symptoms.
Discussion In the present study, the rate of depressed mood was higher during pregnancy compared to the postpartum screening. The rate of depressed mood was 28.3% during the third trimester of pregnancy and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new postpartum cases. The studies which used the same cutoff score as the current study (10 on EPDS) obtained lower rates in pregnancy (17–21.9%) but similar rates postpartum (13–16.8%) [10,22,48]. A study by Andersson et al. [21] reported similar rates during pregnancy and postpartum, but this team evaluated the prevalence of depression and/or anxiety using the PRIME-MD (29.2% during pregnancy and 16.5% in the postpartum period). Given the high comorbidity of symptoms of anxiety and depression in this population, it is not surprising that the rates would be similar, since the EPDS takes into account symptoms of anxiety. The rate of new onset postpartum depressive symptoms in our study is similar to a recent study conducted in USA which reported a rate of new onset postpartum depression of 6% in women at 4–12 weeks following childbirth [13]. While more than half of women reporting elevated depressive symptoms postpartum exhibit elevated symptoms during pregnancy, for a subgroup of women, symptoms only intensify postpartum which underscores the importance of systematically screening both during pregnancy and in the postpartum period. In terms of the course of depressive symptoms, we observed significant reductions in the intensity of depressive symptoms from pregnancy to postpartum in women who completed the postnatal follow-up. This decrease in depressive symptoms from pregnancy to postpartum has also been found in other studies [7,11,13,17]. However, it is difficult to generalize this finding to single women or those of ethnic minority groups, as they were proportionally underrepresented among those who responded in the postnatal period. In the present study, belonging to a non-Caucasian ethnic group, a history of emotional problems or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and having experienced stressful life events were associated with depressed mood during pregnancy. These results are largely consistent with those obtained from other studies on prenatal depression risk factors [18,19,29]. However, some of the factors identified in the present study have received little empirical attention, most notably anxiety sensitivity. To our knowledge, no prior study to date has examined the association between anxiety sensitivity and prenatal depression. However, it has been previously associated with postnatal depression [49]. In other populations, anxiety sensitivity has been examined as a predisposing factor for depression, in particular as a component of fear of cognitive dyscontrol [50–52]. Further research is needed to better understand the relationship between anxiety sensitivity and prenatal depression. A history of sexual abuse was also identified as a predictor of depressed mood during pregnancy, which is consistent with findings of a recent study [53]. It is likely that pregnancy and its implications (e.g. vaginal examinations, bodily changes and feelings of losing control over one’s body) may reactivate
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DOI: 10.3109/0167482X.2014.947953
Factors associated with depressive symptoms during pregnancy and with postpartum onset
painful memories in women who were victims of sexual abuse [54–56]. It is common to observe an increase in symptoms of anxiety and depression during this period, as well as a tendency to avoid prenatal care. It is clear that women with a history of sexual abuse have specific needs for follow-up care. Four risk factors emerged as predictors of depressive symptoms with postpartum onset: higher depressive symptomatology during pregnancy, a history of emotional problems, a delivery that was more difficult than expected and a lower social support during pregnancy. Some of these factors have been widely established in the literature as putting women at risk for PPD, such as prenatal depression and a history of depression [28,57–59]. However, these studies have not always distinguished between postpartum depression that continues from pregnancy and depression with postpartum onset of symptoms. These findings confirm that even among women not experiencing elevated depression during pregnancy (EPDS 10), higher scores below the cutoff range on the EPDS may place women at higher risk postpartum. Childbirth fear when measured in the prenatal period has previously been associated with PPD [60]. In our study, having experienced a more difficult childbirth than expected was independently associated with elevated depressive symptoms in women without prepartum depressed mood. An incongruence between maternal expectations and the actual experience, in addition to feelings of loss, are themes often found in women with PPD [61]. Our findings suggest that a more negative childbirth experience than initially expected may also contribute to the development of new onset postpartum depression. Lower perceived social support during pregnancy was associated with elevated postpartum depressive symptoms in women without prepartum depressed mood. Social support during pregnancy has previously been shown to be associated with postpartum depression [28,57]. While the study conducted by Sidebottom et al. [13] did not find social support to be associated with postpartum onset of depressive symptoms, lack of phone access, which is likely a proxy for extreme poverty and/or social isolation, was significantly associated with postpartum onset of depressive symptoms. Our findings suggest that even among women who are not exhibiting elevated levels of depressed mood during pregnancy, lower perceived social support during pregnancy places these women at greater risk of elevated postpartum depressive symptoms. Our study has several limitations, including its observational design, which precludes any definitive conclusions about the direction of a cause-and-effect relationship. The women in this sample are more educated and have a higher income relative to the Canadian population. Also, single women were under-represented. Thus, the sample may not generalize to all women giving birth in Canada. Cases of depressed mood during pregnancy and the postpartum period were identified using a self-report questionnaire, which is not equivalent to a diagnosis established on the basis of a semistructured interview. Thus, in this study, we refer to the probability of a diagnosis of depression with the term elevated depressive symptoms. We do not know whether depressed mood was present prior to pregnancy and for how long, or whether onset was actually during pregnancy. Finally, there
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may have been a negative response bias in the questionnaires assessing risk factors for women concurrently experiencing depressed mood. Certain risk factors during pregnancy, such as depressed mood and history of emotional difficulties, can help identify women who are at risk of developing PPD. In these cases, a more tailored follow-up could be implemented. For example, Zlotnick et al. [62] found in a pilot study that an interpersonally-oriented group intervention during pregnancy was efficacious in women at high-risk in preventing PPD. Considering the possible consequences of perinatal depression on both mother and infant, interventions should occur as early as possible. Furthermore, the length of delay to adequate treatment is a significant factor in the duration of PPD [27]. Strategies to improve social support during pregnancy, including telephone and online communication [63,64], may also help women to feel more supported during pregnancy and the postpartum period. It may also be important to consider women’s expectations, fears and experiences of childbirth. Finally, certain forms of psychotherapy (e.g. cognitive-behavioural therapy and interpersonal therapy) have been found to be more effective than routine medical care in treating PPD [65]. These treatment options should be considered for women experiencing PPD.
Acknowledgements We thank all the women who took the time to participate in this study.
Declaration of interest None of the authors has a conflict of interest to declare. This study was funded by an operating grant from the Canadian Institutes of Health Research (CIHR) (25933). N.V. was a recipient of a doctoral scholarship from the Social Sciences and Humanities Research Council of Canada (SSHRC) (7522007-1936) and the Fonds que´be´cois de la recherche sur la socie´te´ et la culture (105861).
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ä Current knowledge on this subject Depressive symptoms during pregnancy and the postpartum period are common, under-recognized and poorly treated. Specific demographic, clinical and psychosocial variables have been differentially associated with depressive symptoms during pregnancy and postpartum depression. However, few studies have evaluated risk factors associated with depressive symptoms with onset in the postpartum period. ä What this study adds The rate of depressed mood during pregnancy was 28.3%, and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new cases with onset in the postpartum period. Multiple regression analysis showed that belonging to a non-Caucasian ethnic group, a history of emotional problems or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and experiencing stressful life events were associated with depressed mood during pregnancy. Predictors of depressive symptoms with postpartum onset included lower perceived social support during pregnancy and a delivery that was more difficult than expected. These findings may help to identify and better tailor interventions for women at risk of depression during pregnancy and the postpartum.
