Patterns of peripartum depression and anxiety during the pre-vaccine COVID-19 pandemic

Elevated depression and anxiety symptoms were prevalent throughout pregnancy and postpartum during the COVID-19 pandemic, irrespective of patient SARS-CoV-2 status. Participants who had a history of depression and/or anxiety, as well as those with higher baseline EPDS and GAD-7 scores, were more susceptible to elevated depression and anxiety symptoms during pregnancy and postpartum. Participants who quarantined during pregnancy had higher odds of elevated anxiety symptoms antepartum but not postpartum. On the other hand, those who quarantined during pregnancy did not have increased prevalence of depression. Interestingly, unlike findings in the general population, our participants who tested positive for COVID-19 during pregnancy or were hospitalized during their pregnancy were not more likely to report elevated depression and anxiety symptoms, though our analyses may be underpowered [28]. We describe the prevalence of elevated depression and anxiety symptoms among pregnant patients throughout the peripartum period, including those with confirmed SARS-CoV-2 infections, and identify risk factors associated with peripartum depression and anxiety during the COVID-19 pandemic.

In our study, the prevalence of elevated depression and anxiety symptoms across the peripartum period ranged between 10% and 20%. This is comparable to pre-pandemic rates of peripartum depression and anxiety based on meta-analyses [7, 8]; but lower than published rates of peripartum depression and anxiety during the COVID-19 pandemic [29]. The difference may be partially attributable to differences in EPDS cut-offs for clinical significance. Wu et al. reported 29.6% prevalence of peripartum depression as defined by EPDS score ≥ 10, but subgroup analysis showed 13.9% had EPDS score ≥ 13, which was aligned with our findings. Nevertheless, in a meta-analysis of eight studies by Hessami et al., the overall mean EPDS score during the pandemic was 9.84, and in our cohort the mean EPDS score was between 5.79 at 6–8 weeks postpartum and 7.45 at 6 months postpartum, lower than those reported in the meta-analysis [18, 20]. With regards to anxiety, pooled prevalence for perinatal anxiety across four studies was 50% in a meta-analysis by Shorey et al., noting high heterogeneity between studies [21]. Our cohort may have lower reported rates of elevated depression and anxiety symptoms compared to Hessami et al. and Shorey et al. because we looked prospectively at the prevalence of depression or anxiety symptoms at specific antepartum and postpartum timepoints, not just at any point during the peripartum period. Our cohort includes participants enrolled between March and October 2020, while Hessami et al. looked at participants in February 2020. It is possible that participants enrolled later in the pandemic may have lower rates of depression and anxiety symptoms, than those at the beginning of the pandemic. In the general population, mental health conditions such as depression and anxiety did decrease as the pandemic progressed [30‐33]. Since our cohort included participants enrolled at later time points compared to Hessami et al. it is expected that we would have lower rates of reported depression and anxiety symptoms.

Our study found that the prevalence of both elevated depression and anxiety symptoms increased with gestational age during pregnancy, decreased at 6-8weeks postpartum, and peaked by 6months postpartum. In a meta-analysis published pre-pandemic, depression was more prevalent as pregnancy continued, finding that the average prevalence of depression in the first trimester of pregnancy was 7.4% and increased to 12.0-12.8% by the second or third trimester [34].

Given the impact of depression and anxiety on maternal and neonatal health outcomes, it is imperative for clinicians to identify which pregnant patients are at highest risk for developing depression and anxiety during the COVID-19 pandemic. Our study found that participants at the highest risk for depression and anxiety symptoms during the COVID-19 pandemic included those with a prior history of depression and/or anxiety, observing quarantine, or of Hispanic/Latinx identity. In our cohort, those with prior depression and/or anxiety or those with higher baseline EPDS and GAD-7 scores were more likely to have elevated depression and anxiety symptoms at all antepartum and postpartum timepoints. Prior depression and/or anxiety are well-known risk factors for major depressive disorder with peripartum onset, and the COVID-19 pandemic may contribute further to peripartum depression and anxiety. Moyer et al. found that pregnant individuals with a history of depression or anxiety pre-pandemic were most likely to experience the largest increases in anxiety during the COVID-19 pandemic [35]. This finding is also seen in the general population. Numerous studies have shown that in the general population, those with pre-existing mental health conditions similarly reported higher rates of depression or anxiety during the COVID-19 pandemic [32, 36‐38]. Furthermore, our participants who quarantined during pregnancy had higher rates of elevated anxiety symptoms, but not depression, in the antepartum period. Pregnant patients who felt feelings of isolation had increased rates of symptomatic depression and anxiety and those with better perceived social support actually had lower rates of depression and anxiety [39]. Sommerland et al. found that in 71,117 UK-dwelling participants, those with daily face-to-face or phone/video contact were less likely to report depressive symptoms compared to participants with little social contact, yet this is a non-pregnant population, unlike our study [36]. Our study findings emphasize that in pregnant people with known or suspected COVID-19 pre-existing mental health conditions and/or social isolation are important risk factors for development elevated depression and anxiety symptoms throughout the peripartum course during the pre-vaccine COVID-19 pandemic. The impact on telehealth during COVID-19 should be explored and how this could modify maternal health and/or attenuate risk factors. Thus, it is imperative for health care providers to ask about mental health history in the obstetrics space to identify those at greatest risk for peripartum depression and anxiety.

In our cohort, Hispanic or Latina identity was significantly associated with increased likelihood of elevated anxiety symptoms at 6–8 weeks postpartum. Birthing persons of color have higher rates of postpartum mental health conditions, but are often under screened and under counseled, compared to White persons [40, 41]. Specifically, in a study by Declercq et al., only 18.3% of Latina participants with prenatal depressive symptoms were counseled prenatally on postpartum depression compared to 43.4% of White participants [41]. With racial/ethnic inequities related to mental health screening and access to mental health services among birthing people, our study emphasizes the necessity to screen and counsel all participants for anxiety in antepartum and postpartum period.

Our study does have limitations. We defined elevated depression and anxiety symptoms using EPDS and GAD-7 cut-off scores, not provider-validated clinical diagnoses. EPDS and GAD-7 are validated screening tools frequently used to screen for depression and anxiety in both the research and clinical settings. Past validation studies estimate the sensitivity of EPDS ranging between 65 and 100% and specificity between 49 and 100% [42] and estimate the GAD-7 as having a sensitivity of 89% and specificity of 82% [43]. Although EPDS and GAD-7 are validated screening tools for depression or anxiety, especially for research purposes, they are not diagnostic and thus we may not have accurately identified all participants with clinically significant anxiety/depression in our study. EPDS and GAD-7 do not directly investigate pregnancy-related depression and anxiety. Pregnancy-specific anxiety is a better predictor of poorer birth outcomes compared to general anxiety [21]. Understanding how concerns surrounding childbirth, infant health, and parenting concerns during the COVID-19 pandemic and how they contribute to anxiety and depression experienced during the peripartum period need further exploration, particularly if they impact maternal/neonatal birthing outcomes. We also had challenges establishing a baseline mental health assessment, as participants did not complete the EPDS and GAD-7 pre-pandemic. As such were unable to investigate precisely how the COVID-19 pandemic, including length of hospitalization and visitor policies directly impacted our participants’ mental health. Our study was also limited by the fact that we did not consider how treatment with antidepressants, anxiolytics, and/or psychotherapy may change participants EPDS or GAD-7 scores. Participants treated with antidepressants and anxiolytics possibly have lower EPDS and GAD-7 and as such, might not have been categorized into “symptomatic” depression or anxiety subgroups. Going forward, we hope to gather this information for future studies.