Original Research – QuantitativeA prospective examination of depression, anxiety and stress throughout pregnancy
Introduction
The perinatal period is recognised as a time of major transition that can be extremely emotional,1 and associated with significant distress.2, 3 Symptoms of emotional distress are experienced by a substantial number of women, with international research indicating that depression affects approximately 10–25% of women, while anxiety affects approximately 25–45% of perinatal women.4, 5 The negative consequences of perinatal distress have been well documented and extend not only to the new mother, but also her foetus, child, partner and family (e.g., 6, 7, 8, 9, 10, 11). In turn, there is a clear need to continuously advance our understanding of perinatal distress in an effort to better inform screening, prevention and early detection practices, as well as treatment strategies.
Research to date has primarily defined perinatal distress as the psychological disorders of depression and anxiety,1 which in turn are the two affective states that have received the most research attention. Interestingly, despite this attention and the increased contact that women generally have with health professionals during pregnancy and post birth (in comparison to other time points in their lives), depression and anxiety can often be overlooked and thus left untreated, with approximately half of all cases going unrecognised.12 Perhaps even more neglected, are the early signs of elevated distress levels as well as subclinical symptom levels. In addition, relatively little attention has focused on exploring whether these experiences represent a continuum of symptoms that women may experience prior to the onset of clinical depression. This is especially surprising given that depressive symptoms and anxious features are often identified as risk factors and pre-cursors to postpartum depression.13
Furthermore, when reviewing the literature on the prevalence of perinatal distress, a notable deficit is highlighted in that most prospective studies to date have assessed distress symptoms at only two to three time-points (e.g., 14, 15, 16, 17) with only a few assessing symptoms across four (e.g., 7, 18) or five time-points (e.g., 19, 20). The majority of these studies have also been focused on the postpartum period, rather than pregnancy. Clearly, such research designs do not allow one to assess which distress symptoms demonstrate the earliest onset; what the specific time points are in which the symptoms are escalating; and ultimately at what time-points health professionals may consider intervening in an effort to deliver the most effective treatment plan.
Research has also shown that anxiety symptoms may be more common in perinatal depression in comparison to non-perinatal depression.15, 21 In light of these findings, it has been argued that there is a need to abandon dichotomous classification systems and to discriminate other affective states in the perinatal period, such as perinatal stress22, 23; which has been shown to be present during the first postpartum year and thus may add to the broader and better understanding of perinatal distress.3
Lovibond and Lovibond24 assessed and defined the construct of stress as a measure of persistent, non-specific arousal and tension, with a low threshold for becoming frustrated or upset.24, 25 It is argued that while some symptoms of stress are associated closely with those of anxiety, the experience of stress as a whole entails a coherent set of symptoms that can be differentiated from depression and anxiety. Thus, the existence of such symptoms as a collective may have important implications for any effort to provide a comprehensive understanding of negative affective states,24, 25 and may also be a term that is more readily accepted and associated with less stigma by the wider community. To our knowledge, the point prevalence of stress, with a validated measure that differentiates stress from anxiety and depression during pregnancy, has not been investigated. Past research has indicated that multi-dimensional screening tools such as the Depression Anxiety and Stress Scales (DASS) may be particularly useful, as they allow clinicians to screen for not only depression, as is the case with commonly used instruments such as the Edinburgh Postnatal Depression Scale,26 but also anxiety and stress symptoms within the one brief measure.3
The findings of recent studies also indicate that a cycle of co-morbidity exists between depression and anxiety, whereby initial levels of depressive symptoms in pregnancy lead to higher levels of anxiety in late pregnancy, which in turn predict higher depressive symptoms in the postnatal period.27, 28 A better understanding of these relationships may elucidate the mechanisms that underpin depression and anxiety in the perinatal period. In turn, this understanding may assist in designing interventions to reduce their incidence, subsequent effects and treatment costs. Whether a similar cycle of co-morbidity exists between stress and depression, and stress and anxiety has not been explored to date.
The overall aim of this study was twofold: (1) to examine the trajectory of depression, anxiety and stress symptoms throughout pregnancy on a monthly basis; and (2) to investigate the prospective relationships between depression, anxiety and stress through pregnancy. The impact of social support and sleep quality during early, mid and late pregnancy, were co-varied in the latter analyses, given that they have been shown to be associated with depressive symptoms during the antenatal period.29, 30, 31
Section snippets
Participants
Two hundred and fourteen women were recruited as part of a prospective study. The women were recruited at 10–16 weeks gestation via pregnancy and birth magazines, online forums for expectant and new parents, as well as via word of mouth and community advertising, from various states of Australia. Characteristics of the participant sample are shown in Table 1.
Measures
Demographics Questionnaire. The Demographics Questionnaire obtained information regarding age, weight, annual household income, parity
Data analysis
The results reported from this point forward are based on the six time-points as follows: Time 1 (T1): 16 weeks gestation (M = 16.59 weeks, SD = 0.94); Time 2 (T2): 20 weeks gestation (M = 20.63 weeks, SD = 0.99); Time 3 (T3): 24 weeks gestation (M = 24.46 weeks, SD = 0.86); Time 4 (T4): 28 weeks gestation (M = 28.34 weeks, SD = 0.85); Time 5 (T5): 32 weeks gestation (M = 32.66 weeks, SD = 0.85); Time 6 (T6): 36 weeks gestation (M = 36.50 weeks, SD = 0.75).
Prior to any analyses being conducted, the appropriate
Discussion
The first aim of this study was to attain a comprehensive trajectory of antenatal distress, by exploring levels of depression, anxiety and stress throughout pregnancy. Significant differences were demonstrated in distress levels across time for depression, anxiety as well as stress levels. Results revealed that women's distress symptoms were relatively elevated at 16 weeks gestation, and then again later in pregnancy at 32 and 36 weeks gestation. Thus, symptoms appeared to decrease during the
Conclusion
Depression screening in early pregnancy appears to be particularly pertinent, as it can not only predict later depression, anxiety and stress symptoms as shown in the current study (even after accounting for the effects of social support and sleep quality), but has been shown to predict depression post-birth,27, 28 thus lending further support to the importance of continued depression screening. While the majority of women in the current sample were not experiencing clinical levels of
Acknowledgement
We extend our thanks and appreciation to the women who participated in this research.
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