Abstract
Purpose
Antenatal maternal mental health has been identified as an important determinant of postpartum depression (PPD). We investigated the occurrence of depression both antenatally and postnatally and examined whether maternal trait anxiety and depression during pregnancy were associated with PPD at 8 weeks postpartum in a prospective mother–child cohort (Rhea Study) in Crete, Greece.
Methods
438 women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Trait subscale of the State-Trait Anxiety Inventory (STAI-Trait) questionnaires assessing antenatal depression and anxiety, respectively, during the third trimester of pregnancy as well as the EPDS at 8 weeks postpartum.
Results
The prevalence of women with probable depression (EPDS score ≥13) was 16.7 % at 28–32 weeks of pregnancy and 13.0 % at 8 weeks postpartum. A per 5 unit increase in the STAI-Trait subscale increased the odds for PPD by 70 % (OR = 1.70, 95 % CI 1.41, 2.05), whereas a per unit increase in EPDS during pregnancy increased the odds for PPD by 27 % (OR = 1.27, 95 % CI 1.19, 1.36).
Conclusions
Our findings suggest that antenatal maternal psychological well-being has a significant effect on PPD, which might have important implications for early detection during pregnancy of women at risk for postpartum depression.
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
Introduction
Maternal mental health across the transition from pregnancy to the postnatal period has been the focus of both research and clinical attention during the last decades. Most existing research has focused on depression antenatally or postnatally, whereas less is known about anxiety symptoms during pregnancy. The prevalence of antenatal and postpartum depression (PPD) is similar and ranges from 10 to 15 % [1–6]. Community-based studies—many of which used the Edinburgh Postnatal Depression Scale (EPDS) [7]—indicate that rates of PPD seem to be relatively consistent across countries, although estimates tend to vary when other assessment tools were employed and depending on how the postpartum period time frame was defined. The prevalence of PPD [8, 9] in Greece is similar to that reported in other countries [10, 11].
PPD is considered to be a systemic illness affecting a woman’s functioning and sense of well-being as well as her relationship with her infant and family [12]. Symptoms of PPD occur in the first 6 months after delivery, with onset usually within 2 weeks of childbirth [6, 13]. A range of biological, psychological, socio-demographic and obstetric risk factors have been identified as important determinants of PPD with antenatal maternal mental health being a clearly crucial predictor [6, 14, 15]. Empirical evidence suggests that the strongest predictor of PPD is depression during pregnancy [6, 13, 16–19]. Moreover, antenatal anxiety has been identified as a significant determinant of PPD in a number of community-based studies [16, 19–21] and meta-analyses [6, 15, 21].
Most research into PPD has been conducted in Western industrialised countries [6, 13] and has not taken into account the range of different socio-demographic factors in addition to psychosocial experiences likely to be involved in childbirth, i.e. differences in rates of lone motherhood, the nature of marriage, family and kinship, and variations in the support new mothers receive in different countries and cultures [22]. In an early cross-cultural study conducted in Britain and Greece [23], social support, life events, and emotional well-being during pregnancy were found to predict PPD 4–6 weeks postpartum, whereas history of depression and stressful life events during pregnancy were estimated to have a stronger association with the development of PPD [8, 9, 23].
Antenatal anxiety and depression are powerful predictors of PPD, although it is not clear at which point during pregnancy these psychological states are most predictive of PPD. Antenatal depression increases in severity from the first to the second and the third trimester of pregnancy [25]. A recent meta-analysis found that the rate of depression in the first trimester was similar to rates seen in the general female population, while rates in the second and the third trimester were double as compared to those observed in the general population [1]. Unfortunately, data on prevalence and course of antenatal anxiety during pregnancy are inadequate. In a very recent study, Lee et al. [19] found a U-shaped relationship between stage of pregnancy and anxiety and depressive symptoms during pregnancy, suggesting that both antenatal anxiety and depression decreased from early to mid-pregnancy, but increased again in late pregnancy. The researchers also found that both antenatal anxiety and depressive symptoms predicted PPD. The association between antenatal anxiety symptoms and PPD was found to be increased as pregnancy progressed, with anxiety symptoms in late pregnancy being most strongly associated with PPD, whereas the association between antenatal depressive symptoms and PPD was found to be decreased as pregnancy progressed, with depressive symptoms in early pregnancy being most strongly associated with PPD [19].
Even though symptoms of anxiety and depression during pregnancy often present together indicating high rates of comorbidity [25], empirical evidence suggests that anxiety and depression during pregnancy may have differential effects on PPD. Closing the gap in the evidence regarding the associations between antenatal maternal mental health and PPD has important implications for both families and health-care practitioners. Within the context of a population-based mother–child cohort study in Crete, Greece (Rhea Study), we evaluated whether antenatal maternal mental health—evaluated by means of trait anxiety and depression psychological measures during the third trimester of pregnancy—was associated with PPD at 8 weeks postpartum.
Methods
The mother–child cohort in crete (Rhea Study)
The Rhea Study is a prospective cohort examining a population sample of pregnant women and their children at the prefecture of Heraklion, Crete [26]. Female residents (Greek and immigrants) who had become pregnant during the 12-month period starting in February 2007 were contacted at four maternity clinics in Heraklion and asked to participate in the study. To be eligible for inclusion in the study, women had to have a good understanding of the Greek language and be older than 16 years of age. The first contact was made before week 15 of gestation, at the time of the first major ultrasound examination. Women were then contacted again at 28th–32nd week of gestation, at birth, at 8 weeks, 6 and 18 months postpartum and currently the children are being followed up at 4 years of age. Face-to-face structured interviews, together with self-administered questionnaires and medical records, were used to obtain information on several psychosocial, dietary, and environmental exposures during pregnancy and early childhood. The study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the ethical committee of the University Hospital in Heraklion, Crete, Greece. Written informed consent was obtained from all women participating in the study. Detailed characteristics of the study population have been described elsewhere [26].
During the study period, 1,765 eligible women were approached, 1,610 (91 %) agreed to participate, and 1,388 (86 %) were followed up until delivery. A total of 578 participants completed self-administered questionnaires assessing antenatal trait anxiety and depressive symptoms at 28–32 weeks of gestation, and 1,079 women completed the depression scale at 8 weeks postpartum. A total of 460 women had all three aforementioned questionnaires on anxiety, and antenatal and postnatal EPDS completed. Finally, eight women with a history of past psychiatric disorder and those with twin pregnancies (n = 14) were excluded from the sample, resulting in a cohort of 438 women with no reported previous psychiatric disorder (i.e. indicating new onset of anxiety and depression) available for analyses, resulting in a participation rate of 75.8 % among women with available questionnaires on antenatal maternal mental health who constitute the base population of women with assessed antenatal maternal mental health followed up postnatally with the EPDS.
Measures
Socio-demographic characteristics
Socio-demographic characteristics were collected through questionnaires administered to pregnant women by trained interviewers during the first trimester of pregnancy, such as maternal age, education and origin, marital status, parity, maternal employment status, smoking during pregnancy, and physical activity before and during pregnancy. Infant sex, gestational age, type of delivery, and anthropometric measures at birth were collected from clinical records. Gestational age was based on the interval between the last menstrual period and the date of delivery. When the menstrual estimate of gestational age was inconsistent by seven or more days with the ultrasound measurement taken in the first trimester of pregnancy, a quadratic regression formula describing the relation between crown rump length and gestational age was used instead [26, 27]. Maternal education was divided into three categories: low level: ≤9 years of school, medium level: higher than 9 years of schooling but ≤12 years, and high level: some years in university or university degree. Maternal employment status during pregnancy was categorised as working vs. not working, parity as primiparous vs. multiparous, smoking during pregnancy as yes vs. no, physical activity before and during pregnancy as yes vs. no, planned pregnancy as yes vs. no, and delivery type as vaginal delivery vs. caesarean section.
Psychological assessment both antenatally and postnatally
Women were asked to complete self-reported instruments for antenatal psychological assessment at 28–32 weeks of gestation at home and asked to return them by mail, while postnatal assessment (at 8 weeks postpartum) took place by telephone interview.
Maternal anxiety was measured at 28–32 weeks of gestation using the State-Trait Anxiety Inventory (STAI) [28]. It is a 40-item scale made up of two 20-item subscales (one state and one trait) and has been widely used to asses anxiety not only in clinical, but in non-clinical samples. Only the STAI-Trait subscale was used for the purposes of the present study. Trait anxiety reflects relatively stable individual differences in anxiety proneness. Each item of the trait subscale is scored on a 4-point scale ranging from 1 (almost never) to 4 (almost always). The STAI is a widely used index of anxiety symptoms and has considerable validity, reliability, and clinical utility. The STAI has been translated and validated in Greek [29] and has been found to have satisfactory psychometric properties.
(Cronbach’s a for STAI-State subscale α = 0.92 and for STAI-Trait subscale α = 0.89).
Maternal depressive symptoms were assessed—antenatally at 28–32 weeks of gestation and postnatally at 8 weeks postpartum—using the Edinburgh Postnatal Depression Scale (EPDS) [7]. The EPDS is a widely used 10-item self-report questionnaire providing an indication of the severity of mother’s mood during the past 7 days. Items are rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (most of the time) and refers to depressed mood, anhedonia, guilt, anxiety, and suicidal ideation. The EPDS is the only rating scale for depression validated during both the antenatal and the postnatal period [30]. A cutoff score of 13 or greater on the EPDS has been found to identify probable clinical postnatal depression with a sensitivity of 86 % and a specificity of 78 % [7, 31]. The EPDS has been translated and validated for the Greek population by two research groups [9, 32] and showed a very high overall internal consistency. Cronbach’s alpha for the total scale was equal to 0.90 in the validation study of Leonardou et al. [9] and 0.80 in the validation study of Vivilaki et al. [32].
Potential confounders
Potential confounders included characteristics that have an established or potential association with antenatal maternal mental health and PPD including: maternal age at delivery; maternal education (low level: ≤9 years of school, medium level: higher than 9 years of school but ≤12 years, and high level: some years in university or university degree, ref: low level); maternal employment status during pregnancy (working vs. not-working); parity (primiparous/multiparous); smoking during pregnancy (yes vs. no); physical activity before and during pregnancy (yes vs. no); planned pregnancy (yes vs. no); child’s gender (boy vs. girl); delivery type (caesarean vs. vaginal delivery).
Statistical analyses
The primary outcome variable of interest was the EPDS score at 8 weeks postpartum. The primary exposures of interest were antenatal STAI-Trait and EPDS scores. Scores entered the analyses as continuous or categorical variables. EPDS was used as a continuous (both antenatal and postnatal EPDS scores) and as a categorical variable with a cutoff score of 13 (only postnatal EPDS scores) or greater as recommended by Cox et al. [7], which appeared to be an effective screening for probable clinical depression indicating high levels of postpartum depressive symptoms. No clinical cutoff has been established for the STAI-Trait subscale. To obtain a cutoff score for STAI-Trait, the sample mean plus one standard deviation was used. Thus, those who scored above 48 on the STAI-Trait were categorised as “high” in trait anxiety. Antenatal and postpartum EPDS failed the normality test (Kolmogorov–Smirnov with Lilliefors significance correction); hence, nonparametric statistical tests were applied in univariate analyses.
Bivariate associations between categorical dependent and independent variables were studied using Pearson’s Chi-square test for categorical variables (with Fisher correction for groups with <5 subjects). Bivariate associations between continuous dependent and categorical independent variables were studied using either Student’s t test (normally distributed continuous dependent variables) or nonparametric statistical methods (Mann–Whitney, Kruskal–Wallis) for non-normally distributed continuous dependent variables. Pearson’s or Spearman’s rho correlation coefficient was used to estimate the strength of the association between continuous dependent and independent variables.
Multivariable linear and logistic regression models were fit to estimate the association between trait anxiety and depression during pregnancy with maternal depressive symptoms at 8 weeks postpartum. Variables related with either the outcome or the exposure of interest in the bivariate associations with a p < 0.2 were included in the multivariable models as potential confounders, as well as a priori selected potential confounders such as maternal age and maternal education. Estimated associations are described in terms of odds ratios (OR) with 95 % confidence intervals (CIs) (logistic regression models) or β coefficients and 95 % CIs (linear regressions models). Antenatal STAI-Trait and EPDS scores were highly correlated, so as to avoid multicollinearity which increases the standard errors of the coefficients; antenatal EPDS and STAI-Trait scores were entered as independent variables into separate models. To account for the possibility of residual confounding by antenatal EPDS, the association between maternal trait anxiety and postnatal EPDS also were estimated excluding women with high scores of antenatal EPDS. In addition, to account for the possibility of residual confounding by antenatal STAI-Trait, the association between maternal antenatal EPDS and postnatal EPDS were estimated also excluding women with high scores of antenatal STAI-Trait. All association testing was conducted assuming a 0.05 significance level and a two-sided alternative hypothesis. Additionally, we applied generalised additive models (GAMs) to explore the shape of the relationships between antenatal EPDS and STAI-Trait scores with postnatal EPDS [33]. These models indicated linear relationships with postnatal EPDS and antenatal EPDS and STAI-Trait scores, after adjusting for confounders. Restricted quadratic spline models, as well as Lowess smooth were used to plot the observed associations.
All statistical analyses were performed using PASW Statistics 19 software (SPSS Inc, Chicago, IL, USA).
Results
Table 1 presents the socio-demographic characteristics of the study participants. 418 (95.4 %) of the participants were of Greek origin, 242 (57.2 %) were multiparous, 396 (91.2 %) were married or cohabiting, with a mean age at delivery of 29.77 years (SD = 4.68). Among newborns, 48 (11.0 %) were born prematurely (<37 weeks of gestation) and 216 (49.4 %) of the deliveries were caesarean. 252 (58.9 %) of the pregnancies were planned pregnancies. The comparison between the 438 participants and the 140 non-participants (i.e. women with complete antenatal maternal mental health questionnaires who did not participate in the postpartum study) revealed few significant differences between the two groups. Mothers who participated in postnatal psychological assessment were more likely to have high levels of education and to be non-smokers as compared to non-participants.
STAI-Trait was positively correlated with antenatal EPDS (ρ = 0.694, p < 0.001), while postnatal EPDS was found to be positively related with STAI-Trait (r = 0.459, p < 0.001) and antenatal EPDS (r = 0.454, p < 0.001). Mean scores for depression were higher in pregnancy than postnatally. Specifically, the antenatal mean EPDS was 7.71 (SD = 4.95), while the mean EPDS score at 8 weeks postpartum was 6.48 (SD = 4.90). The proportion of women with probable depression (EPDS score ≥13) was 16.7 % at 28–32 weeks of pregnancy (n = 73) and 13.0 % at 8 weeks postpartum (n = 57), with 29 women scoring high on the EDPS scale indicating clinical depression in both periods. The proportion of women with high levels of anxiety (STAI-Trait score ≥48) was 17.8 % at 28–32 weeks of pregnancy (n = 78). Finally, 11.4 % of the women had high levels of both anxiety and depression during pregnancy (n = 50).
Table 2 presents the associations of maternal mental health both antenatally and postnatally with infant’s and maternal socio-demographic characteristics. Women with low levels of education and those who did not work during pregnancy had significantly higher scores on antenatal EPDS. Moreover, women who did not plan their pregnancies and those who did not exercise before or during pregnancy tended to report higher symptoms of antenatal trait anxiety and depression. Higher rates of PPD were reported by mothers who gave birth to boys and those who had a caesarean section delivery.
Table 3 presents the crude and adjusted associations between antenatal maternal mental health and PPD as a continuous variable at 8 weeks postpartum. In the multivariable analysis, it was estimated that for every 1 unit increase in the antenatal maternal depressive score there was a 0.51 unit increase in PPD (β coefficient 0.51, 95 % CI 0.42, 0.59), while for every 5 units increase in the antenatal maternal anxiety scale there was 1.25 units increase in PPD (β coefficient 1.25, 95 % CI 1.00, 1.51). The relationship between antenatal EPDS and PPD proved remarkably robust when sensitivity analysis was conducted following the exclusion of 78 women with higher anxiety levels (STAI-Trait score ≥48) (β coefficient 0.38, 95 % CI −0.42, 0.59). The same was true for the association between antenatal trait anxiety and PPD following the exclusion of 73 women with antenatal EPDS score ≥ 13 (β coefficient 0.92, 95 % CI 0.63, 1.20).
Table 4 summarises the associations between antenatal depression and anxiety and high levels of postpartum depressive symptoms (EPDS ≥ 13). Specifically, a per 5 unit increase in the STAI-Trait subscale was associated with a 70 % increase in the odds for PPD (OR = 1.70, 95 % CI 1.41, 2.05), whereas a per unit increase in antenatal EPDS was associated with a 27 % increase in the odds for PPD (OR = 1.27, 95 % CI 1.19, 1.36). These associations were supported by sensitivity analyses as well. After exclusion of 78 women with STAI-Trait score ≥48, a per unit increase in antenatal EPDS increased the odds for PPD by 18 % (OR = 1.18, 95 % CI 1.07, 1.29); whereas after the exclusion of 73 women with antenatal EPDS score ≥13, a per 5 unit increase in the STAI-Trait subscale increased the odds for PPD by 36 % (OR = 1.18, 95 % CI 1.03, 1.79).
GAMs examining the shape of the relationships between postnatal EPDS with antenatal EPDS and STAI-Trait scores showed no significant departures from linearity, both for antenatal EPDS (P-gain = 0.536) and STAI-Trait (P-gain = 0.621) scores (Fig. 1).
Discussion
The present study was carried out to provide insight into the early assessment of PPD by exploring the association of antenatal maternal mental health with maternal mood in the postpartum period in Crete, Greece. The results of our study suggest that maternal trait anxiety and depressive symptoms during pregnancy are significantly associated with PPD at 8 weeks postpartum, a finding that is consistent with previous research [6, 13, 15–21] The findings also indicated that the effect of antenatal maternal anxiety or depressive symptoms on postpartum depressive symptoms are not likely to be a result of residual confounding due to antenatal EPDS or STAI-Trait, respectively, although replication of such analyses in other population samples would be desirable.
By excluding women with a history of past psychiatric disorder, the present study examined new onset of antenatal anxiety and depression, as well as PPD. Depressive symptoms were found to be higher in pregnancy than in the postnatal period. Antenatal psychological states appear to be dynamic and changing in nature, with most studies demonstrating a generally increasing trend of depressive symptoms and anxiety during pregnancy followed by a decline after childbirth [2, 16], thus highlighting the significance of antenatal mental health problems. It is not clear at which point during pregnancy symptoms of anxiety and depression are most predictive of PPD. Antenatal depressive symptoms may occur during any trimester, but increases in depressive symptoms seem to be most likely between 18 and 32 weeks of pregnancy [2], with symptoms being more prevalent and severe during the third trimester [19]. It seems that women who are anxious in the final trimester are those with most difficulty in adjusting to the maternal role and least confident in meeting the demands of motherhood [19].
Given the high prevalence and serious consequences of both antenatal and postnatal depression, efforts have been made to identify risk factors to assist in prevention, identification, and treatment. In our sample, findings in the univariate analysis indicated that low level of mother’s education and unemployment were associated with antenatal depression in univariate analysis similarly to previous findings [34]. Moreover, unplanned pregnancy was related to both antenatal depression and anxiety. Consistent with other study findings [18, 35], an unplanned or unwanted pregnancy, and the accompanying feelings, might be trigger for antenatal anxiety and depression. Preliminary evidence in the literature showed that unwanted or unplanned pregnancy places women under great psychological risks [36]; however these studies did not examine its varying importance across different stages of pregnancy [19].
In our study, women who had no physical activity before or during pregnancy tended to report higher symptoms of anxiety and depression during pregnancy. In a number of studies, participation in physical activity was associated with lower levels of depressive symptoms [37, 38], even though in other studies no associations between total or recreational physical activity and depressive symptoms were found [39, 40]. Physical exercise has long been thought to benefit mental health and is an attractive, low-risk and low-cost approach to the management of depression and anxiety during pregnancy and postnatally.
Our results indicated that higher rates of PPD were reported by mothers who gave birth to boys and those who had a caesarean section delivery, although the mean scores in EPDS postpartum compared for both variables were still quite low, thus the differences might not seem to be clinically meaningful in our sample. However, as far as infant sex is concerned, our findings supported the results of previous studies that women who gave birth to boys were significantly more likely to suffer from severe PPD than women who gave birth to girls [41]. Interestingly, the same research group found that even if women did not have PPD, giving birth to a boy was significantly more likely to reduce their quality of life than delivering a girl. However, our findings were in contrast with the finding of previous studies in China [42], Turkey [43], and India [44], which found that rates of PPD were higher among women who had given birth to girls. This could be explained by the fact that women who live in cultures where greater value is placed on sons are more likely to suffer from PPD if they give birth to a girl. In a similar vein, some research has linked caesarean section delivery with higher rates of PPD compared to vaginal delivery [45–47], and this may be due to the discrepancies in oxytocin release and the time it takes to recover from the procedure, as well. However, the link between caesarean section and depression is still unclear [48]. As previously described [45–47], the proportion of caesarean sections is very high in this population and this high percentage is not believed to be due to medical conditions.
In the current study, the prevalence of depressive symptoms in late pregnancy was 16.7 and 13.0 % at 8 weeks postpartum and is similar to other reported prevalence rates in Western countries. However, comparisons are compromised by varying follow-up data in relation to delivery, variation in EPDS thresholds, and selection problems when samples are on specified populations [2, 5, 49–51]. In Greece, research on PPD has yielded similar findings to those reported in the literature. A recent study found that PPD had an overall prevalence of 19.8 % and a point prevalence of 12.5 % at the end of the 1 month after delivery [8]. Leonardou et al. [9], using the non-patient version of the structured clinical interview for DSM-III-R (SCID), found that 12.4 % of the participants suffered from depression at 2 months postpartum.
The strengths of the present study include the population-based, prospective follow-up design, reasonable numbers of women with PPD symptoms, and detailed data for maternal mental health in terms of trait anxiety and depressive symptoms during pregnancy. The study population included women followed up since early pregnancy, providing us the opportunity to account prospectively for the effect of exposures during pregnancy. Furthermore, the exclusion of women who gave birth to twins and women with a previous history of psychiatric disorder as well as adjustment for several socio-demographic variables reduced the likelihood of confounding. We did not observe any substantial differences between the crude and adjusted models. Thus, it is unlikely that over-adjustment affected our findings. Participants were unaware of the hypothesis being tested, so, misclassification of mental health scores estimated by the questionnaires is likely to be random with respect to PPD scores.
There are, however, some limitations in the present study that deserve acknowledgement. A possible limitation is the participation rate (75.8 %) together with the differences found between participants and non-participants. We could hypothesise that due to the non-participants’ profile, they might have been women with higher levels of anxiety and/or prenatal depressive symptoms. If however our hypothesis, which is supported by current findings, is correct then even stronger associations between antenatal maternal mental health and PPD might have been detected. In addition, as the lower response rate was not due to loss to follow-up which can also produce selection bias in a cohort study, biasing estimates toward unknown direction, we are quite confident that the direction of the association is most probably toward the null. Although we consider that these differences observed at baseline are not likely to have affected appreciably the present results, this limitation should be taken into account when considering study findings; it is difficult to understand the direction of bias, which depends on what the association between antenatal maternal health and PPD would be for non-participants, which cannot be tested. Furthermore, we assessed antenatal and postpartum depressive symptoms with the self-reported EPDS scale and trait anxiety with the self-reported STAI-Trait subscale, rather than definite cases of depression and anxiety based on clinician-administered structured diagnostic interview. However, this is an epidemiological study assessing the prevalence of antenatal/postpartum depression and trait anxiety, and EPDS and STAI-Trait scores are established and widely used screening tools with high specificity and sensitivity [52, 53]. Furthermore, a setback of our study was that we did not use a questionnaire to evaluate marital satisfaction and perceived social support, which have been identified as protective factors for maternal mental health both antenatally and postnatally. Finally, no questions were asked about stressful life events and a history of abuse. Research suggests that stressful life events, such as the death of a loved one, relationship breakdowns or divorce, losing a job or moving away from home, as well as low social support during pregnancy and early puerperium, have been shown to contribute to the onset of PPD [6, 15, 54]. Furthermore, although the present study examined the relationship of new onset of anxiety and depression during pregnancy and PPD by excluding women with a history of past psychiatric disorder, there still may be the possibility of residual confounding due to past history of adversity or mental health problems not captured in this study or due to other unknown social and lifestyle variables. Τhe exclusion criteria of only eight women with a history of past psychiatric disorder might render some overinterpretation of newly onset anxiety and depression, although the results would likely not change if these participants were included. Further research therefore is needed to replicate findings for newly onset mental health conditions in pregnancy and the postpartum.
Notwithstanding these limitations, our study serves as an important step toward recognising the dynamic nature of anxiety and depression across pregnancy and the postpartum period. Antenatal depression and anxiety are found to be strongly associated with PPD at 8 weeks postpartum in a sample of Greek mothers. With the exclusion of women with a history of past psychiatric disorder, the present study highlights the contribution of newly onset anxiety and depressive symptoms in late pregnancy to PPD. Future research should encourage the longitudinal assessment of both anxiety and depression across all three trimesters and during the first postnatal year as well, for examining how these psychological states change across pregnancy and at the postpartum period. Research findings have shown that antenatal anxiety and depression are not static, but instead show a changing course, both in prevalence rates and in intra-individual anxiety and depression levels [19]. Clinicians should be vigilant of potential cases of anxiety and depression emerging in different stages of pregnancy, with ongoing screening being done throughout.
Worldwide research has been accumulated over the last two decades, emphasising the need for special care of women during pregnancy and the postpartum period. Antenatal and postnatal maternal mental health might have a significant adverse impact, not just on the affected woman, but on her family as a whole. Our group has recently shown that both antenatal and postnatal maternal psychological well-being have important consequences on early child neurodevelopment [55]. The findings of the present study suggest that antenatal maternal psychological well-being has a significant effect on PPD, which might have important implications for early detection during pregnancy of women at risk for PPD. Consequently, a longitudinal analysis of antenatal anxiety and depression across different stages of pregnancy is of great value for developing effective prevention and early intervention strategies.
References
Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR (2004) Prevalence of depression during pregnancy: systematic review. Obstet Gynecol 103(4):698–709
Evans J, Heron J, Francomb H, Oke S, Golding J (2001) Cohort study of depressed mood during pregnancy and after childbirth. BMJ 323(7307):257–260
Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T (2005) Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 106(5 Pt 1):1071–1083
Halbreich U, Karkun S (2006) Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 91(2–3):97–111
Josefsson A, Berg G, Nordin C, Sydsjo G (2001) Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 80(3):251–255
O’Hara M, Swain A (1996) Rates and risk of postpartum depression: a meta-analysis. Intl Rev Psychiatr 8(1):37–54
Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150:782–786
Gonidakis F, Rabavilas AD, Varsou E, Kreatsas G, Christodoulou GN (2008) A 6-month study of postpartum depression and related factors in Athens, Greece. Compr Psychiatry 49(3):275–282
Leonardou AA, Zervas YM, Papageorgiou CC, Marks MN, Tsartsara EC, Antsaklis A, Christodoulou GN, Soldatos CR (2009) Validation of the Edinburgh Postnatal Depression Scale and prevalence of postnatal depression at 2 months postpartum in a sample of Greek mothers. J Reprod Infant Psyc 27(1):28–39
Cox JL, Murray D, Chapman G (1993) A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 163:27–31
Nonacs R, Cohen LS (2002) Depression during pregnancy: diagnosis and treatment options. J Clin Psychiatry 63(Suppl 7):24–30
O’Hara MW (1997) The nature of postpartum depressive disorders. In: Murray L, Cooper P (eds) Postpartum depression and child development. Guilford, New York, pp 3–31
Llewellyn AM, Stowe ZN, Nemeroff CB (1997) Depression during pregnancy and the puerperium. J Clin Psychiatry 58(Suppl. 2):26–32
Beck CT (1996) A meta-analysis of predictors of postpartum depression. Nurs Res 45(5):297–303
Beck CT (2001) Predictors of postpartum depression: an update. Nurs Res 50(5):275–285
Heron J, O’Connor TG, Evans J, Golding J, Glover V (2004) The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord 80(1):65–73
Larsson C, Sydsjo G, Josefsson A (2004) Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms. Obstet Gynecol 104(3):459–466
Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ, Joffe H, Gilman MW (2006) Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Commun H 60:221–227
Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY (2007) Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 110(5):1102–1112
Austin M-P, Tully L, Parker G (2007) Examining the relationship between antenatal anxiety and postnatal depression. J Affect Disord 101(1–3):169–174
Robertson E, Grace S, Wallington T, Steward DE (2004) Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiat 26(4):289–295
Oates MR, Cox JL, Neema S, Asten P, Glangeaud-Freudenthal N, Figueiredo B, Gorman LL, Hacking S, Hirst E, Kammerer MH, Klier CM, Seneviratne G, Smith M, Sutter-Dallay A-L, Valoriani V, Wickberg B, Yoshida K, Group atT-P (2004) Postnatal depression across countries and cultures: a qualitative study. Br J Psychiatry 184(Suppl. 46):S10–S16
Thorpe KJ, Dragonas T, Golding J (1992) The effects of psychosocial factors on the emotional well-being of women during pregnancy: a cross-cultural study of Britain and Greece. J Reprod Infant Psyc 10(4):191–204
Hoffman S, Hatch MC (2000) Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women. Health Psychol 19(6):535–543
Field T, Diego M, Hernandez-Reif M, Figueiredo B, Deeds O, Ascencio A, Schanberg S, Kuhn C (2010) Comorbid depression and anxiety effects on pregnancy and neonatal outcome. Infant Behav Dev 33(1):23–29
Chatzi L, Plana E, Daraki V, Karakosta P, Alegkakis D, Tsatsanis C, Kafatos A, Koutis A, Kogevinas M (2009) Metabolic syndrome in early pregnancy and risk of preterm birth. Am J Epidemiol 170(7):829–836
Westerway SC, Davison A, Cowell S (2000) Ultrasonic fetal measurements: new Australian standards for the new millennium. Aust N Z J Obstet Gynaecol 40(3):297–302
Spielberger C, Gorsuch R, Lushene R, Vagg P, Jacobs G (1970) Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press, Palo Alto
Liakos A, Giannitsi S (1984) Reliability and validity of the modified Greek version of the Spielberger State-Trait Anxiety Inventory. Encephalos 21:71–76
Murray L, Carothers AD (1990) The validation of the EPDS on a community sample. Br J Psychiatry 157:288–290
Matthey S, Henshaw C, Elliot S, Barnett B (2006) Variability in use of cut off scores and formats on the Edinburgh Postnatal Depression Scale—implications for clinical and research practice. Arch Womens Ment Health 9(6):309–315
Vivilaki VG, Dafermos V, Kogevinas M, Bitsios P, Lionis C (2009) The Edinburgh Postnatal Depression Scale: translation and validation for a Greek sample. BMC Public Health 9:329
Wood SN (2006) Generalized additive models: an introduction with R. Chapman and Hall/CRC Press, Boca Raton
Rubertsson C, Waldenstrom U, Wickberg B (2003) Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample. J Reprod Infant Psyc 21(2):113–123
Bunevicius R, Kusminskas L, Bunevicius A, Nadisauskiene RJ, Jureniene K, Pop VJ (2009) Psychosocial risk factors for depression during pregnancy. Acta Obstet Gynaecol Scand 88:599–605
Bowen A, Muhajarine N (2006) Antenatal depression. Can Nurse 102(9):26–30
Da Costa D, Rippen N, Dritsa M, Ring A (2003) Self-supported leisure-time physical activity during pregnancy and relationship to psychological well-being. J Psychosom Obst Gyn 24(2):111–119
Haas JS, Jackson RA, Fuentes-Afflick E, Stewart AL, Dean ML, Brawarsky P, Escobar GJ (2004) Changes in the health status of women during and after pregnancy. J Gen Intern Med 20(1):45–51
Goodwin A, Astbury J, McMeeken J (2000) Body image and psychological well-being in pregnancy. A comparison of exercisers and non-exercisers. Aust N Z J Obstet Gynaecol 40(4):442–447
Poudevigne MS, O’Connor PJ (2005) Physical activity and mood during pregnancy. Med Sci Sports Exerc 37(8):1374–1380
de Tychey C, Briancon S, Lighezzolo J, Spitz E, Kabuth B, de Luigi V, Messembourg C, Girvan F, Rosati A, Thockler A, Vincent S (2008) Quality of life, postnatal depression and baby gender. J Clin Nurs 17(3):312–322
Xie RH, Liao S, Xie H, Guo Y, Walker M, Wen SW (2011) Infant sex, family support and postpartum depression in a Chinese cohort. J Epidemiol Commun Health 65(8):722–726
Ekuklu G, Tokuc B, Eskiocak M, Berberoglu U, Saltik A (2004) Prevalence of postpartum depression in Edirne, Turkey, and related factors. J Reprod Med 49(11):908–914
Patel V, Rodrigues M, DeSouza N (2002) Gender, poverty, and postnatal depression: a study of mothers in Goa, India. Am J Psychiatry 159(1):43–47
Edwards DRL, Porter SAM, Stein GS (1994) A pilot study of postnatal depression following caesarean section using two retrospective self-rating instruments. J Psychosom Res 38(2):111–117
Hannah P, Adams D, Lee A, Glover V (1992) Links between early postpartum mood and postnatal depression. Br J Psychiatry 160:777–780
Lobel M, DeLuca RS (2007) Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications. Soc Sci Med 64:2272–2284
Carter FA, Frampton CM, Mulder RT (2006) Cesarean section and postpartum depression: a review of the evidence examining the link. Psychosom Med 68(2):321–330
Green JM, Murray D (1994) The use of the Edinburgh Postnatal Depression Scale in research to explore the relationships between antenatal and postnatal dysphoria. In: Cox J, Holden J (eds) Perinatal psychiatry: use and misuse of the Edinburgh Postnatal Depression Scale. Gaskell, London, pp 180–198
Johanson R, Chapman G, Murray D, Johnson I, Cox J (2000) The North Staffordshire maternity hospital prospective study of pregnancy-associated depression. J Psychosom Obstet Gynaecol 21(2):93–97
Marcus S, Flynn H, Blow F, Barry K (2003) Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health 12(4):373–380
Harris B, Huckle P, Thomas R, Johns S, Fung H (1989) The use of rating scales to identify post-natal depression. Br J Psychiatry 154:813–817
Thompson WM, Harris B, Lazarus J, Richards C (1998) A comparison of the performance of rating scales used in the diagnosis of postnatal depression. Acta Psychiatry Scand 98(3):224–227
Seguin L, Potvin L, St Denis M, Loiselle J (1999) Depressive symptoms in the late postpartum among low socioeconomic status women. Birth 26:157–163
Koutra K, Chatzi L, Bagkeris M, Vassilaki M, Bitsios P, Kogevinas M (2012) Antenatal and postnatal maternal mental health as determinants of infant neurodevelopment at 18 months of age in a mother-child cohort (Rhea Study) in Crete, Greece. Soc Psychiatry Psychiatr Epidemiol 48(8):1335–1345
Acknowledgments
The Rhea cohort was supported by European projects (EU FP6-2003-Food-3-A NewGeneris, EU FP6. STREP HiWATE, EU FP7 ENV.2007.1.2.2.2. Project No 211250 Escape, EU FP7-2008-ENV-1.2.1.4 EnviroGenoMarkers, EU FP7-HEALTH-2009- single-stage CHICOS, EU FP7 ENV.2008.1.2.1.6. Proposal No 226285 ENRIECO) and by the Greek Ministry of Health (Program of Prevention of Obesity and Neurodevelopmental Disorders in Preschool Children, in Heraklion district, Crete, Greece: 2011–2014). We are grateful to all those who participated in the study, especially the mothers and their infants, and the whole Rhea team for their contribution and understanding.
Conflict of interest
The authors have no conflicts of interest to declare.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Koutra, K., Vassilaki, M., Georgiou, V. et al. Antenatal maternal mental health as determinant of postpartum depression in a population based mother–child cohort (Rhea Study) in Crete, Greece. Soc Psychiatry Psychiatr Epidemiol 49, 711–721 (2014). https://doi.org/10.1007/s00127-013-0758-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00127-013-0758-z