Antenatal risk factors for postpartum depression: a synthesis of recent literature

Postpartum nonpsychotic depression is the most common complication of childbearing, affecting approximately 10-15% of women and, as such, represents a considerable health problem affecting women and their families. This systematic review provides a synthesis of the recent literature pertaining to antenatal risk factors associated with developing this condition. Databases relating to the medical, psychological, and social science literature were searched using specific inclusion criteria and search terms, in order to identify studies examining antenatal risk factors for postpartum depression. Studies were identified and critically appraised in order to synthesize the current findings. The search resulted in the identification of two major meta-analyses conducted on over 14,000 subjects, as well as newer subsequent large-scale clinical studies. The results of these studies were then summarized in terms of effect sizes as defined by Cohen. The findings from the meta-analyses of over 14,000 subjects, and subsequent studies of nearly 10,000 additional subjects found that the following factors were the strongest predictors of postpartum depression: depression during pregnancy, anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, low levels of social support, and a previous history of depression. Critical appraisal of the literature revealed a number of methodological and knowledge gaps that need to be addressed in future research. These include examining specific risk factors in women of lower socioeconomic status, risk factors pertaining to teenage mothers, and the use of appropriate instruments assessing postpartum depression for use within different cultural groups.     

Risk factors for antenatal depression: A review

Depression is the most prevalent mental disorder in pregnancy, and yet it is less studied than postpartum depression despite the consequences it may have on both the pregnant woman and her offspring. Therefore, it would be important to know which risk factors may favour the appearance of antenatal depression in order to carry out appropriate prevention interventions. The aim of the present review was to identify the main risk factors of antenatal depression. We searched in databases PubMed and PsycINFO for articles published about the factors associated with antenatal depression from January 2010 through December 2020. The literature review identified three main groups of antenatal depression risk factors: sociodemographic, obstetric, and psychological. First, among the sociodemographic variables, the low level of studies and the economic income clearly stood out from the rest. Then, not having planned the pregnancy was the main obstetric variable, and finally, the main psychological risk factors were having a history of psychological disorders and/or depression as well as presenting anxiety, stress, and/or low social support during pregnancy. This review shows that the antenatal depression is affected by multiple factors. Most can be identified at the beginning of the pregnancy, and some are risk factors potentially modifiable through appropriate interventions, such as psychological factors. For this reason, it is important to carry out a good screening for depression during pregnancy and consequently, be able to prevent its appearance or treat it if necessary.     

Postnatal Depression in Surabaya,Indonesia

Postnatal depression or postpartum depression is a major psychiatric illness affecting many women with uncertainty remaining over causative factors or etiology [1]. The Edinburgh Postnatal Depression Scale, used for the first time in Indonesia, evaluated demographic data and risk factors to determine any correlation of women with and without postpartum depression. Some 434 women attending antenatal care were included in the study beginning the third term of pregnancy and concluded four to six weeks postpartum. Finding of 22.35 percent of postnatal mothers reporting postpartum depression in our study is similar to other studies. No significant differences were found between women with and without postpartum depression when evaluating demographic variables. Significant differences between the two groups were found when comparing risk factors. Also, women who had more risk factors had postpartum depression. The need for educational programs to create awareness and assist in identifying the condition early is important. Finally, ongoing support of mothers during the postpartum period is necessary in preventing postpartum depression.     

Depression During Pregnancy and Postpartum

Depression is a common complication of pregnancy and the postpartum period. There are multiple risk factors for peripartum mood disorders, most important of which is a prior history of depression. Both depression and antidepressant medications confer risk upon the infant. Maternal depression has been associated with preterm birth, low birth weight, fetal growth restriction, and postnatal cognitive and emotional complications. Antidepressant exposure has been associated with preterm birth, reductions in birth weight, persistent pulmonary hypertension, and postnatal adaptation syndrome (PNAS) as well as a possible connection with autism spectrum disorder. Paroxetine has been associated with cardiac malformations. Most antidepressant medications are excreted in low levels in breast milk and are generally compatible with breastfeeding. The use of antidepressants during pregnancy and postpartum must be weighed against the risk of untreated depression in the mother.     

The relationship between alexithymia and perinatal depressive symptomatology

OBJECTIVE: The purpose of this study was to examine the relationship between alexithymia and perinatal depressive symptoms and the stability of the alexithymia construct in a sample of low-income, predominantly Latina women during pregnancy and the early postpartum period. METHODS: Seventy-seven pregnant women completed self-report questionnaires and were classified as "high risk" or "low risk" for developing a major depressive episode based on a history of depression and/or current high depressive symptom scores. Measures included the Toronto Alexithymia Scale, the Center for Epidemiological Studies Depression Scale, and the Maternal Mood Screener, and were completed during pregnancy and at postpartum month 2. RESULTS: Alexithymia was positively associated with depressive symptoms during pregnancy and early postpartum. Women at high risk for depression had significantly higher alexithymia levels than low-risk women during pregnancy but not during postpartum. Alexithymia and depressive symptoms were independently and strongly correlated across the ante- and postpartum periods. Hierarchical regression analyses indicate that alexithymia scores at postpartum were predicted by alexithymia scores during pregnancy, above and beyond the variance explained by the depressive symptom scores during pregnancy and postpartum. CONCLUSION: Alexithymia is positively correlated with depressive symptoms during the perinatal period and is a stable phenomenon.     

Predictors of postpartum depression: Prospective study of 264 women followed during pregnancy and postpartum

The prevalence of postpartum depression is approximately 13%. Postpartum depression is associated with a higher maternal morbidity and mortality, and also with pervasive effects on the emotional, cognitive and behavioral development of the child. The aim of our study was to identify socio-demographic, psychosocial and obstetrical risk factors of postpartum depression in a middle class community sample, using a prospective design. We enrolled consecutively 312 pregnant outpatients in a single maternity unit. The first assessment was conducted between 32 and 41 weeks gestation, and a second time between 6 and 8 weeks after delivery. Depressive symptoms were measured using the French version of the Edinburgh Postnatal Depression Scale (EPDS). A cut-off score of 12/30 or above was considered as indicative of Major Depression. Of the initial sample of 312 women, 264 (84.6%) were followed-up between 6 and 8 weeks after delivery and considered for analysis. Depression during pregnancy, migrant status, and physical abuse by the partner were independently associated with postpartum depression when considered together, whereas physical complications were significantly associated with postpartum depression only when adjusting for antenatal depression. Depression during pregnancy, history of physical abuse, migrant status and postpartum physical complications are four major risk factors for postpartum depression.     

From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset of depression. Results from the perinatal depression-research & screening unit study

Objective

Perinatal depression is a particular challenge to clinicians, and its prevalence estimates are difficult to compare across studies. Furthermore, to our knowledge, there are no studies that systematically assessed the incidence of perinatal depression. The aim of this study is to estimate the prevalence, incidence, recurrence, and new onset of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, minor and major depression (mMD) in an unselected population of women recruited at the third month of pregnancy and followed up until the 12th month postpartum.

Method

One thousand sixty-six pregnant women were recruited. Minor and major depression was assessed in a naturalistic, longitudinal study. The Edinburgh Postnatal Depression Scale and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Disorders were administered at different time points during pregnancy and in the postpartum period.

Results

The period prevalence of mMD was 12.4% in pregnancy and 9.6% in the postpartum period. The cumulative incidence of mMD in pregnancy and in the postpartum period was 2.2% and 6.8%, respectively. Thirty-two (7.3%) women had their first episode in the perinatal period: 1.6% had a new onset of depression during pregnancy, 5.7% in the postpartum period.

Conclusions

Our postpartum prevalence figures, which are lower than those reported in the literature, may reflect treatment during the study, suggesting that casting a multiprofessional network around women in need of support may be potentially useful for reducing the effects of this disorder on the mother and the newborn child. Furthermore, our results indicate that women with a history of depression have a 2-fold risk of developing mMD in the perinatal period.     

Genetic variants in the tryptophan hydroxylase 2 gene (TPH2) and depression during and after pregnancy

BackgroundA number of studies indicate that altered serotonergic transmission may be a risk factor for depression in the peripartum period. The aim of this study was to investigate whether genetic polymorphisms in the TPH2 gene, the gene product of which is the rate-limiting enzyme in the biosynthesis of serotonin in the central nervous system, are associated with depressive symptoms in pregnancy and the postpartum period.MethodsIn a cohort of 361 Caucasians, the severity of depression was assessed prospectively during pregnancy (third trimester) and the postpartum period (2–3 days and 6–8 months) using the Edinburgh Postnatal Depression Scale (EPDS). Tagging single nucleotide polymorphisms (SNPs) in TPH2 and SNPs that are known to be of functional relevance were genotyped. For each haplotype block or SNP, a multifactorial linear mixed model was performed to analyse the EPDS values over time.ResultsThe haplotype block in the promoter region of TPH2 showed significant associations with depression values during pregnancy and 6–8 months afterwards. Additionally, a haplotype block in intron 8 had an influence on depression values during pregnancy, but not after birth. There was a significant interaction between time and haplotypes and the severity of depression. The effect of TPH2 haplotypes on EPDS values was strongest during pregnancy and 6 months after birth, with a low depression rating in the first few days after delivery for all women.ConclusionsIn this cohort, TPH2 haplotypes known to be of functional relevance were found to be associated with different EPDS values during and after pregnancy. These haplotypes were associated with depressive symptoms both before and after delivery and were thus not specific for postpartum-onset depression. This underlines the relevance of these functional polymorphisms for depression in general and the importance of longitudinal assessments in research on postpartum depression.     

Depression during pregnancy: detection,comorbidity and treatment

Depression during pregnancy is common (～15%). Routine prenatal depression screening coupled with the use of physician collaborators to assist in connecting women with care is critical to facilitate treatment engagement with appropriate providers. Providers should be aware of risk factors for depression – including a previous history of depression, life events, and interpersonal conflict – and should appropriately screen for such conditions. Depression during pregnancy has been associated with poor pregnancy outcomes including preeclampsia, insufficient weight gain, decreased compliance with prenatal care, and premature labor. Current research has questioned the overall benefit of treating depression during pregnancy with antidepressants when compared to the risk of untreated depression for mother and child. Published guidelines favor psychotherapy above medication as the first line treatment for prenatal depression. Poor neonatal adaptation or withdrawal symptoms in the neonate may occur with fetal exposure in late pregnancy, but the symptoms are mild to moderate and transient. The majority of mothers who decide to stop taking their antidepressants during pregnancy suffer relapsing symptoms. If depression continues postpartum, there is an increased risk of poor mother–infant attachment, delayed cognitive and linguistic skills in the infant, impaired emotional development, and behavioral problems in later life. Bipolar depression, anxiety and substance use disorders, and/or presence of severe psychosocial stress can lead to treatment‐resistance. Modified and more complex treatment algorithms are then warranted. Psychiatric medications, interpersonal or cognitive‐behavioral therapy, and adjunctive parent–infant/family treatment, as well as social work support, are modalities often required to comprehensively address all issues surrounding the illness.     

Social support, life events, and depression during pregnancy and the puerperium

A sample of 99 women was studied prospectively from the second trimester of pregnancy until nine weeks post partum. Depressed and nondepressed women identified at the second-trimester assessment and the postpartum assessment were compared on measures of stressful life events and social support provided by their spouses and close confidants. Nine percent of women during pregnancy and 12% of women after delivery were depressed. Women experiencing postpartum depression reported more stressful life events and less support from their spouses after delivery than the women not experiencing postpartum depression. Women experiencing depression during pregnancy reported somewhat less support from their spouses and more support from their confidants than nondepressed women. The results of the study suggest that different causes may be responsible for prepartum and postpartum depression.     

Sociodemographic risk factors of perinatal depression: a cohort study in the public health care system

ObjectiveTo assess the sociodemographic risk factors for the prevalence and incidence of relevant postpartum depressive symptoms.MethodWe studied a cohort of women in their perinatal period with the assistance of the public health system in the city of Pelotas-RS, Brazil. We assessed depressive symptoms with the Edinburgh Postnatal Depression Scale (EPDS) in the prenatal and postnatal periods.ResultsWe interviewed 1,109 women. The prevalence of meaningful depressive symptoms during pregnancy was 20.5% and postpartum was 16.5%. Women with prenatal depression were at higher risk for postpartum depression.ConclusionThe mother's poverty level, psychiatric history, partner absence and stressful life events should be considered important risk factors for relevant postpartum depressive symptoms.     

Risk factors for early postpartum depressive symptoms

OBJECTIVE: Postpartum depressive disorders are common and symptoms may appear as early as the first 2 weeks postpartum. Data regarding hormone-related risk factors for depressive symptoms occurring in the very early postpartum period are scarce and may be of importance in identifying serious postpartum illness. We examined the association between the reported history of psychiatric symptoms of possible hormonal etiology and very early postpartum depressive symptoms. METHODS: All women (n= 1,800) in a general hospital maternity ward were assessed during the first 3 days after parturition for potential risk factors for postpartum depressive disorders by a self-reported questionnaire and for present mood symptoms (Edinburgh Postnatal Depression Scale, EPDS). The associations between potential risk factors and postpartum depressive symptoms were analysed. RESULTS: The incidence of women with an EPDS >or=10 was 6.8% (88/1,286). Significant risk factors for early postpartum depressive symptoms were a history of mental illness including past postpartum depression (PPD), premenstrual dysphoric disorder (PMDD), and mood symptoms during the third trimester. CONCLUSION: In accordance with other studies, a history of depression was found to be a risk factor for early postpartum mood symptoms. An association was also found between some risk factors of possible hormone-related etiology such as PMDD and third trimester mood symptoms and early postpartum mood symptoms. As such, early postpartum symptoms may indicate vulnerability to subsequent PPD; it may be of importance to assess these risk factors and mood immediately after parturition. A prospective study is needed to determine which of these risk factors is associated with progression to PPD and which resolves as the blues.     

Prospective study of postpartum blues. Biologic and psychosocial factors

Potential biologic and psychosocial causative factors for the postpartum blues were tested in a prospective study of 182 women followed up from the second trimester of pregnancy until postpartum week 9. Personal and family history of depression, depressive symptoms, stressful life events, and social adjustment were all assessed during the second trimester. Levels of progesterone, prolactin, estradiol, free and total estriol, and free and total cortisol were measured on several occasions during late pregnancy and early puerperium. Obstetric and child-care stressors and the postpartum blues were assessed after delivery. Predictors of the postpartum blues were personal and family history of depression, social adjustment, stressful life events, and levels of free and total estriol. Our results support the hypothesis that the postpartum blues is within the spectrum of affective disorders.     

Maternal anxiety: course and antecedents during the early postpartum period

The early course and antecedents of postpartum anxiety are unknown. This study sought to determine the course and antecedents of maternal anxiety during the first month postpartum and to develop a model to predict 1-month anxiety using information obtainable before perinatal hospital discharge. Two hundred and ninety-six mothers were screened before discharge with the State (SS) and Trait (TS) Scales of the State Trait Anxiety Inventory (STAI). Demographic characteristics were assessed by questionnaire and medical record review, and psychiatric history, measures of perinatal stress, and resilient factors were determined by focused questions and formal instruments. At 1-month postpartum, the SS was repeated. Scores on the SS were significantly higher at 1 month than immediately postpartum (35.30+/-0.68 versus 33.38+/-0.60, mean+/-standard error, P=.004), but only 58.6% of mothers with high pre-discharge anxiety had high anxiety at 1 month. One-month anxiety correlated with pre-discharge SS and TS scores, a history of psychiatric problems including depressed mood, medical and negative social life events, lack of pregnancy planning and prenatal class attendance, perceived peripartum stress, and duration of postpartum hospital stay. Inverse correlations were observed with education, household income, and resiliency factors. In multivariate modeling, anxiety trait, education, history >or=2 years of depression, and perception of peripartum stress accounted for 50% of the variance in the 1-month SS score. Maternal anxiety increases during the first postpartum month. Women with high trait anxiety, low education, a history of depressed mood, and a perception of high peripartum stress are at risk for experiencing anxiety at this time.     

Antenatal thyroid correlates of postpartum depression

We previously found significantly higher T3-resin uptake and nearly significantly lower total thyroxine concentrations at 38 weeks of pregnancy in women with higher postpartum depression ratings. This study further examined the relationship between thyroid status during late pregnancy and antenatal and postpartum depression scores. Thyroid measures were obtained at 32-35, 36, and 37 weeks of pregnancy in 31 women with normal range thyroid hormone levels. Subjects rated their mood at these antenatal time points and every other week between postpartum weeks 2 and 24 on the Edinburgh Postnatal Depression Scale and the Beck Depression Inventory. Mean antenatal thyroxine concentrations and free thyroxine indices correlated significantly and negatively with mean depression scores during each of three postpartum time periods (postpartum weeks 2-6, 14-18, 20-24). Women with total and free thyroxine concentrations that were, respectively, <10.1 microg/dl and <1.06 ng/dl at all three antenatal time points had significantly higher mean depression scores during all postpartum time periods. The fraction of subjects with pregravid major or minor depression history that was in the low antenatal thyroid group was significantly higher than the fraction of subjects with negative history (5/6 vs. 7/25). Women with antenatal total and free thyroxine concentrations in the lower euthyroid range may be at greater risk of developing postpartum depressive symptoms. Study of the relationships with antenatal thyroid status may provide new insights into the pathophysiology of perinatal mood disturbances.     

Depression during pregnancy and postpartum: Contribution of stress and ovarian hormones

Depression is the most common psychiatric disease among women, exhibiting a prevalence which is 2–3× higher than in men. The postpartum period is considered the time of greatest risk for women to develop major depression and postpartum depression affects approximately 15% of women. A dysregulation of the hypothalamus–pituitary–adrenal (HPA) axis is the most prominent endocrine change seen in depression and normalization of the HPA axis is a major target of recent therapies. Females exhibit different stress sensitivities than males which might contribute to their increased vulnerability for depression. Maternal stress or depression during pregnancy and/or postpartum is particularly concerning as early developmental influences can affect the maturation of the offspring as well as the mental health of the mother. Despite the urgent need for more information on depression in females, especially during pregnancy and postpartum, most animal models of depression have utilized only males. Given the sex differences in incidence of depression and treatment, it is vitally important to create or validate animal models of depression in females. This review will focus on the association between stress, glucocorticoids and depression in humans, with a special focus on depression in women during pregnancy and postpartum and on animal models of postpartum depression and the consequences for the offspring.     

Postpartum depression: we know the risks, can it be prevented?

In the past 20 years, there has been increasing recognition that for some women, pregnancy may be burdened with mood problems, in particular depression, that may impact both mother and child. With identification of risk factors for postpartum depression and a growing knowledge about a biologic vulnerability for mood change following delivery, research has accumulated on attempts to prevent postpartum depression using various psychosocial, psychopharmacologic, and hormonal strategies. The majority of psychosocial and hormonal strategies have shown little effect on postpartum depression. Notwithstanding, results from preliminary trials of interpersonal therapy, cognitive-behavioural therapy, and antidepressants indicate that these strategies may be of benefit. Information on prevention of postpartum depression using dietary supplements is sparse and the available evidence is inconclusive. Although a few studies show promising results, more rigorous trials are required. The abounding negative evidence in the literature indicates that postpartum depression cannot be easily prevented, yet.     

Pregnancy complications and neonatal outcomes in women with eating disorders

OBJECTIVE: This study reported pregnancy complications and neonatal outcomes for 49 live births in a group of women with eating disorders who were prospectively followed. METHOD: Subjects were recruited from 246 women participating in a longitudinal study of anorexia nervosa and bulimia nervosa, now in its 12th year. Subjects were interviewed by trained assistants and completed a brief self-report instrument that assessed both birth statistics and birth-related complications. Medical records and/or self-report data describing the neonates' birth status were obtained. RESULTS: The majority of the women with eating disorders had normal pregnancies, resulting in healthy babies. Across the group, the mean length of pregnancy was 38.7 weeks, the mean birth weight was 7.6 lb, and mean Apgar scores at 1 and 5 minutes after birth were 8.2 and 9.0, respectively. Most outcomes were positive; however, three babies (6.1%) had birth defects, and 17 (34.7%) of the women experienced postpartum depression. The mean number of obstetric complications in the group was 1.3, and 13 (26.5%) of the women delivered by cesarean section. Women who showed symptoms of either anorexia nervosa or bulimia nervosa during pregnancy had a higher frequency of birth by cesarean section and postpartum depression than did nonsymptomatic women. CONCLUSIONS: Pregnant women with active eating disorders appear to be at greater risk for delivery by cesarean section and for postpartum depression. Pregnant women with past or current eating disorders should be viewed as being at high risk and monitored closely both during and after pregnancy to optimize maternal and fetal outcomes.     

Corticotropin-releasing hormone and cortisol: longitudinal associations with depression and antisocial behavior in pregnant adolescents

OBJECTIVE: To examine the concurrent and longitudinal associations between corticotropin-releasing hormone (CRH) and cortisol concentrations and depression and antisocial behavior (conduct disorder symptoms) in pregnant adolescents. METHOD: Fifty-nine adolescents were evaluated in early pregnancy (9-21 weeks' gestation), late pregnancy (32-34 weeks' gestation), and the postpartum period (4-5 weeks postpartum). Symptoms of depression and conduct disorder were obtained from the Diagnostic Interview Schedule for Children. RESULTS: Lower concentrations of CRH were related to a greater number of depression symptoms in early pregnancy (p < .05) and in late pregnancy (p < .05). Lower concentrations of CRH also were related to a greater number of conduct disorder symptoms in early pregnancy (p < .06) and in the postpartum period (p < .05). CONCLUSION: The findings support the long-standing hypothesis that stress-related products of the hypothalamic-pituitary-adrenal axis are associated with emotions and behavior during pregnancy.     

孕期家庭亲密度适应性对产妇产后抑郁的影响

目的分析孕期家庭亲密度适应性对产妇产后抑郁的影响。方法选取2013-03-2014-03我院收治的晚期妊娠孕妇160例为研究对象,分别于产前和产后6周采用爱丁堡产后抑郁量表和家庭亲密度适应性量表对其进行调查。结果观察组和对照组实际适应性和适应性不满意程度评分相比,差异具有统计学意义(t=-3.509,2.657;P均0.05)。观察组和对照组实际亲密度和亲密度不满意程度评分相比,差异具有统计学意义(t=-2.472,3.005;均P0.05)。实际适应性、适应性不满意程度、实际亲密度和亲密度不满意程度是产后抑郁的影响因素。结果孕期家庭亲密度适应性差会导致产妇产后抑郁,护理人员要重视对家庭亲密度重要性的宣传,降低产妇产后抑郁发生率。