Journal Article Annotations
2018, 2nd Quarter

Women’s Mental Health

Annotation by Priya Gopalan, MD
July 2018

Association of persistent and severe postnatal depression with child outcomes

PUBLICATION #1 — Women’s Mental Health

Association of persistent and severe postnatal depression with child outcomes

Netsi E, Pearson RM, Murray L, Cooper P, Craske MG, Stein A

Abstract: JAMA Psychiatry 2018; 75(3):247-253

Importance: Maternal postnatal depression (PND) is common and associated with adverse child outcomes. These effects are not inevitable, and it is critical to identify those most at risk. Previous work suggests that the risks of adverse outcomes are increased when PND is severe and persistent, but this has not been systematically studied.

Objective: To examine the association between differing levels of persistence and severity of PND and long-term child outcomes.

Design, Setting, and Participants: The sample for this observational study comprised participants in the Avon Longitudinal Study of Parents and Children in the United Kingdom. Three thresholds of PND severity-moderate, marked, and severe-were defined using the self-rated Edinburgh Postnatal Depression Scale (EPDS). Depression was defined as persistent when the EPDS score was above the threshold level at both 2 and 8 months after childbirth. For each of these severity and persistence categories, the following were examined: (1) the trajectories of later EPDS scores (6 time points between 21 months and 11 years after childbirth) and (2) child outcomes-behavioral problems at 3.5 years of age, school-leaving mathematics grades at 16 years of age, and depression at 18 years of age. Data analysis was conducted from July 12, 2016, to February 8, 2017.

Main Outcomes and Measures: Child behavioral problems at 3.5 years of age using the Rutter total problems scale, school-leaving mathematics grades at 16 years of age extracted from records of external national public examinations, and offspring depression at 18 years of age using the Clinical Interview Schedule-Revised.

Results: For the 9848 mothers in the sample, the mean (SD) age at delivery was 28.5 (4.7) years. Of the 8287 children, 4227 (51%) were boys and 4060 (49%) were girls. Compared with women with PND that was not persistent and women who did not score above the EPDS threshold, for all 3 severity levels, women with persistent PND showed elevated depressive symptoms up to 11 years after childbirth. Whether persistent or not, PND doubled the risk of child behavior disturbance. The odds ratio (OR) for child behavioral disturbance for mothers with moderate PND was 2.22 (95% CI, 1.74-2.83), for mothers with marked PND was 1.91 (95% CI, 1.36-2.68), and for mothers with severe PND was 2.39 (95% CI, 1.78-3.22). Persistence of severe PND was particularly important to child development, substantially increasing the risk for behavioral problems at 3.5 years of age (OR, 4.84; 95% CI, 2.94-7.98), lower mathematics grades at 16 years of age (OR, 2.65; 95% CI, 1.26-5.57), and higher prevalence of depression at 18 years of age (OR, 7.44; 95% CI, 2.89-19.11).

Conclusions and Relevance: Persistent and severe PND substantially raises the risk for adverse outcome on all child measures. Meeting criteria for depression both early and late in the postnatal year, especially when the mood disturbance is severe, should alert health care professionals to a depression that is likely to be persistent and to be associated with an especially elevated risk of multiple adverse child outcomes. Treatment for this group should be prioritized.

On PubMed: JAMA Psychiatry 2018; 75(3):247-253

Annotation

Type of study: Observational cohort study

The finding: This is a prospective, longitudinal observational study of women in the UK with postpartum depression, measured across multiple time points (2 months and 8 months postpartum) with evaluation of both depressive symptoms in mother and behavioural symptoms in children until the child was 18 years old. The study found that women’s mean Edinburgh Postnatal Depression Scale (EPDS) scores stayed stable over time. Children of women with persistent PND were at higher risk of behavioural problems at 3.5 years: moderate severity OR, 3.04; 95%CI, 2.10-4.38 and marked severity (OR, 2.84; 95%CI, 1.71-4.71) when compared to children of women with PND that was not persistent at any level of severity. Whether persistent or not, the presence of postpartum depression doubled the risk of child behavior disturbance. Persistent depression had the most significant adverse outcomes for children including at age 16 and 18. Persistent and severe postpartum depression substantially raised the risk for adverse outcome on all child measures used in the study.

Strength and weaknesses: Strengths of the study included the large sample size for postnatal depression overall and the longitudinal, long-term follow-up. A postpartum depression study of this length is unusual. Another big strength of the study is that there was stratification of depression severity and persistence. The primary weakness is the relatively small sample size in the group of women with persistent and severe postpartum depression, owing in part to high attrition rates. Controls were kept to a minimum (maternal education only).

Relevance: C-L psychiatrists seeing pregnant and postpartum patients in either inpatient or outpatient settings should be aware of the elevated risks associated with persistent postpartum depression. As EPDS scores remained stable across time and as severe and persistent depression caused adverse childhood outcomes across childhood and adolescence, these risks should be weighed against risks of medications and presented to pregnant and postpartum patients as a risk of untreated illness. This adds to the growing body of literature that suggests that untreated depression in the perinatal period has significant implications on the wellbeing of the baby, and in this case, has long-term implications.