Depression, anxiety, PTSD and comorbidity in perinatal women in Turkey: A longitudinal population-based study

Highlights

• Perinatal affective disorders are common in Turkey.

• Depression and PTSD were most prevalent after birth (32.6% and 11.9%, respectively).

• Anxiety was most prevalent in pregnancy (29.6%).

• Depression and anxiety were highly comorbid after birth.

• New-onset cases were identified at 4–6 weeks and 6-months postpartum.

Abstract

Objective: (a) to assess prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) and their comorbidity among women during the perinatal period (b) to examine course of those disorders from pregnancy to 6 months postpartum (c) to determine the rates of new-onset cases at 4-6 weeks and 6 months postpartum.

Design: A longitudinal population-based study in which participants completed psychosocial measures of depression, anxiety and PTSD in pregnancy (n = 950), 4-6 weeks (n = 858) and 6 months (n = 829) after birth.

Setting: A consecutive sample of pregnant women were recruited from three maternity hospitals in three cities of Turkey: Istanbul, Ankara and Izmir.

Measures: Edinburgh Postnatal Depression Scale (EPDS), Hospital Anxiety and Depression Scale (HADS), and Posttraumatic Diagnostic Scale (PDS) were used to assess depression, anxiety and PTSD, respectively.

Findings: Depression and PTSD peaked at 4-6 weeks postpartum and then fell at 6 months postpartum, whereas anxiety followed a gradually declining linear-pattern from pregnancy to 6 months postpartum. The prevalence of depression was 14.6% in pregnancy, 32.6% at 4-6 weeks and 18.5% at 6 months postpartum, respectively. The prevalence of PTSD was 5.8% in pregnancy, 11.9% at 4-6 weeks postpartum and 9.2% at 6 months postpartum. Anxiety was highest in pregnancy (29.6%) and then decreased to 24.6% 4-6 weeks after birth and to 16.2% 6 months after birth. New-onset cases were most apparent at 4-6 weeks postpartum: 24.6% for depression; 13.7% for anxiety and 8.9% for PTSD.

Key conclusions: A relatively high prevalence of psychological disorders was identified during the perinatal period. Anxiety was most prevalent in pregnancy, and depression and PTSD were highest at 4-6 weeks postpartum. Depression was more common than anxiety 4-6 weeks and 6 months after birth and highly comorbid with anxiety throughout this period. New-onset cases were observed at both 4-6 weeks and 6 months postpartum.

Implications: High rates of affective disorders in pregnancy and after birth highlight three main points: first, it is important to have effective perinatal screening to identify women with psychological needs; second, providing early treatment to women experiencing severe psychological problems is essential to ensure psychological well-being of those women and to prevent chronicity; and finally, psychosocial screening and interventions should be offered until at least 6 months after birth to catch new-onset cases.

Introduction

Perinatal affective disorders are common and constitute a significant health problem all over the world. There has been a growing interest in mental health during pregnancy and after birth in recent years, yet relatively little is known about women from Middle East countries, including Turkey (Klainin and Arthur, 2009, O’Mahony et al., 2010). There are significant differences between countries in awareness, prevalence rates, and treatment of perinatal mental health disorders (Rahman et al., 2013). Consequently, the World Health Organization (WHO) has developed an action plan to ensure the effective provision of perinatal mental health care and the equity of outcomes across the world (WHO, 2013). A review of women's mental health in pregnancy and after birth carried out by the WHO, found that women in low- and middle-income countries are at increased risk with an average prevalence of 16% reporting prenatal and 20% reporting postnatal psychological disorders (Fisher et al., 2012).

Common perinatal mental health disorders include depression, anxiety and PTSD. Depression is broadly defined as a state of low mood or loss of pleasure or interest in activities, while anxiety is generally characterised by feelings of tension, worried thoughts and physical changes (American Psychiatric Association, 2013). Post-traumatic stress disorder (PTSD) refers to a cluster of psychological symptoms that develop following exposure to a severe stressor or traumatic event (Fink, 2010).

Despite being well-recognised, studies on perinatal affective disorders have predominantly focused on postpartum depression. There are therefore gaps in the literature in both high and low- and middle- income countries (Howard et al., 2014). First, perinatal anxiety has been far less researched compared to perinatal depression (Agius et al., 2016, Goodman et al., 2016), although there is adequate evidence that anxiety may be as or more prevalent than depression during the perinatal period (Brockington et al., 2006, Fairbrother et al., 2016, Lee et al., 2007, Paul et al., 2013 ). A recent review reported that the prevalence of anxiety disorder is 15.8% in pregnancy and 17.1% after birth (Fairbrother et al., 2016). Two other reviews also found that anxiety disorders are diagnosed between 4% and 39% of pregnant women and 8.5% of postpartum women (Goodman et al., 2016, Goodman et al., 2014). Both pre- and postpartum anxiety are associated with an adverse impact on maternal and child health (Alder et al., 2007, Ding et al., 2014, Dunkel Schetter and Tanner, 2012, Glover, 2015).

Second, there is increasing evidence women may have PTSD in pregnancy and develop PTSD as a result of a traumatic birth. A recent review found the prevalence of PTSD was 3.3% in pregnancy and 4% after birth (Yildiz et al., 2017). However, most research on perinatal PTSD using diagnostic measures has been conducted in Western countries (Yildiz et al., 2017). The course of PTSD after birth also remains little understood (McKenzie-McHarg et al., 2015).

Third, even though previous literature on the comorbidity of depression, anxiety and PTSD is abundant in different populations, particularly in war veterans (Ginzburg et al., 2010), there is a lack of research on the comorbidity of depression, anxiety and PTSD in perinatal period (Agius et al., 2016, Reck et al., 2009). In a recent review, three studies were identified examining the multimorbidity of depression, anxiety and PTSD after birth and the prevalence was found as ranging from 2% to 3%; (Agius et al., 2016). However, no study investigating the multimorbidity in pregnancy has been identified (Agius et al., 2016). The multimorbidity of depression, anxiety and PTSD during perinatal period may compound the psychological distress the woman has already experienced, perpetuate the course of each, maintain the occurrence, and result in poorer treatment outcomes. Hence, there is a need to understand more profoundly the nature and prevalence of comorbidity of these aforementioned disorders.

Finally, many studies on perinatal mental health have used cross-sectional designs (George et al., 2013). This is problematic given the fact that postpartum psychological disorders are frequently preceded by antepartum psychopathology. Longitudinal research is important to determine whether postpartum disorders are new cases or pre-existing psychological disorders present in pregnancy. Evidence on the course of anxiety is also mixed with contradictory findings as to whether anxiety increases or decreases after birth (Ayers et al., 2015).

Turkey is a middle-income country which is undergoing a period of rapid social and economic change. This may impact upon the rates and prevalence of perinatal mental health. The nature and the extent of perinatal affective disorders may differ in women with non-Western backgrounds, which would also have implications for diagnosis and treatment. However, research on Turkish women's perinatal mental health is still in its infancy in Turkey. Studies that have been conducted, largely focus on depression and find high prevalence rates ranging from 10.9% to 28% in pregnancy (Eskici et al., 2012, Ortaarik et al., 2012, Yanikkerem et al., 2013) and 13.5 to 28.3% after birth (Ozbasaran et al., 2011, Ozmen et al., 2014). A few studies have investigated antenatal anxiety with varying rates from 29% to 40.5% (Arslan et al., 2011, Ortaarik et al., 2012, Tunc et al., 2012). This research suggests perinatal affective disorders may be highly prevalent in Turkey. However, this research is limited in scope and methodology, with the majority of studies conducted on relatively small samples using cross-sectional designs. The research also predominantly focuses upon depression and has not much examined postpartum anxiety or perinatal PTSD in Turkey. This study addresses these gaps and examines PTSD, anxiety and depression during and after pregnancy in a large sample of Turkish women.

In light of the gaps identified, the aims of the study were: (i) to determine the prevalence of depression, anxiety and PTSD in pregnancy, at 4–6 weeks and 6 months after birth in a longitudinal manner, (ii) to examine the course of each from pregnancy to 6 months postpartum, (iii) to examine comorbidity of depression, anxiety and PTSD at three assessment time points.