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This is what postnatal depression really feels like

by Rachel Leonard, Anne Grant And Mark Linden, The Conversation

Credit: AI-generated image

Motherhood can be a source of joy, but it can also pose difficulties and challenges – particularly, in the postnatal period. It is a time when some mothers' emotional and physical endurance is pushed to the limit.

About 10% of pregnant women and 13% of women who have just given birth experience a mental illness, primarily depression and anxiety. In developing countries 20% of mothers experience clinical depression after childbirth.

Mothers who have mental health problems after giving birth, face the dual challenges of managing motherhood alongside their health issue. This balancing act can cause an internal conflict – but fears of being judged and shame around what they are experiencing can act as a barrier, which stops many women from seeking help.

There is an expectation that having a baby will result in the rosy glow of motherhood. But postnatal depression can leave many women with a persistent feeling of deep sadness, and a loss of interest in life. This may reduce their ability to care for their baby, or may leave them with thoughts of self-harm or even suicide.

A mother's mask

We conducted interviews with mothers with mental health problems during the postnatal period. These were gathered as part of a larger study, which explored the family focused practice of health visitors who work with these women.

We found that while mothers wanted support, there were barriers to accepting it. The mothers we spoke to felt fear, shame and guilt about being a mother with poor mental health. These feelings led to the mothers covering up their deteriorating mental health, from family, friends and professionals.

And with an expectation of happiness, the reality of parenthood mixed with suffering from postnatal depression can be a hard one to accept – as one of the mothers we spoke to explained: "I didn't feel a connection to the baby, and that was stressing me out even more. I was thinking I need to feel something here; I need to feel like fireworks going off here." (Mother of one, age 37)

With this internal conflict, mothers describe feelings of guilt and shame about their mental health problems, coupled with a belief that they were not deserving of motherhood: "I truly at times looked at these two kids and thought, you deserve better than me who is sitting here and can't get dressed for days. What sort of life am I giving you?" (Mother of two, age 34)

The mothers in our study also spoke about fearing the judgement of society, believing that society equates mental health problems with bad parenting: "I was getting more and more anxious. They're looking at me, they're thinking I'm a terrible mother, I am a terrible mother." (Mother of three, age 38)

One of the mother spoke about the fears that her children would be taken away from her if she told people how she was really feeling – believing that people would view her as "not being a fit mummy". Many of the mothers we spoke to talked about going to great lengths to hide their struggles with their mental health – from both their family, friends and the outside world: "You have that mask that you put on for society. And then you have days where you just don't want to wear that mask so you just stay in the house." (Mother of two, age 32)

The mothers also felt they are judged more harshly than fathers, due to widely held assumptions that women have instinctual love for their children.

The reality of motherhood

To some extent, western society has moved beyond traditional gender roles, yet mothers still predominately take on the bulk of care giving responsibilities for children. And as our research shows mothers feel stigmatised and fear judgement – which can result in them covering up their deteriorating mental health.

Our research also highlights how a lack of openness around mental health problems, can mean these women will not be identified and cannot receive appropriate support. Without support there is a risk that their mental health will deteriorate further, potentially resulting in negative outcomes for all the family.

Services need to develop a deeper understanding of the impact of poor mental health on mothers and provide opportunities for mums to openly discuss parenting and mental health, in a judgement free environment.

Assumptions and expectations of motherhood, also need to be re-examined, and discussed more openly with the general public, as the rosy glow of motherhood does not reflect the universal experience of all mothers.

Provided by The Conversation 

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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• Introduction
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Trajectories of internalizing symptoms are shown from age 14 years through 22 to 28 years, estimated using group-based trajectory modeling.

For female participants, the increase in odds was greater in contexts of lower socioeconomic adversity, and for male participants, the increase in odds was greater in contexts of higher socioeconomic adversity.

Participants were stratified by socioeconomic adversity index in 3 groups: those with scores 1 SD below the mean, from −1 SD below the mean to and 1 SD above the mean, and greater than 1 SD above the mean. For female participants, the increase in odds was greater in contexts of low socioeconomic adversity, while for male participants, the increase in odds was greater in contexts of high socioeconomic adversity. The upper bound of the CI for male participants in the greater than 1 SD above the mean category (ie, 10.14) has been cut to 6 for visual purposes.

eTable 1. Fit Indices of Confirmatory Factor Analysis Model for Socioeconomic Adversity Index

eTable 2. Marginal Probabilities for 3-Way Interaction Among Postnatal Depression, Socioeconomic Adversity, and Sex in the Association With Offspring Internalizing Symptoms

eFigure 1. 3-Way Interaction Among Postnatal Depression, Socioeconomic Adversity, and Sex in the Association With Offspring Internalizing Problems

eFigure 2. 3-Way Interaction Estimated Using Each Indicator Composing Socioeconomic Adversity Index

• Psychosocial Factors Associated With Children’s Development—Maternal Depression JAMA Network Open Invited Commentary August 19, 2021 Sarah K. G. Jensen, PhD, MSc; Theresa S. Betancourt, ScD, MA

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Orri M , Besharati S , Ahun MN , Richter LM. Analysis of Maternal Postnatal Depression, Socioeconomic Factors, and Offspring Internalizing Symptoms in a Longitudinal Cohort in South Africa. JAMA Netw Open. 2021;4(8):e2121667. doi:10.1001/jamanetworkopen.2021.21667

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Analysis of Maternal Postnatal Depression, Socioeconomic Factors, and Offspring Internalizing Symptoms in a Longitudinal Cohort in South Africa

• 1 McGill Group for Suicide Studies, Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, Québec, Canada
• 2 Bordeaux Population Health Research Centre, Inserm U1219, University of Bordeaux, Bordeaux, France
• 3 Department of Psychology, University of the Witwatersrand School of Human and Community Development, Johannesburg, South Africa
• 4 Department of Social and Preventive Medicine, Université de Montréal School of Public Health, Montréal, Québec, Canada
• 5 Department of Science and Innovation-National Research Foundation Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
• Invited Commentary Psychosocial Factors Associated With Children’s Development—Maternal Depression Sarah K. G. Jensen, PhD, MSc; Theresa S. Betancourt, ScD, MA JAMA Network Open

Question   Is there an interaction with socioeconomic adversity in the association between postnatal maternal depression and offspring internalizing symptoms in low-and-middle income countries (LMICs)?

Findings   In this cohort study among 1087 individuals born in Soweto, South Africa, maternal depression 6 months after childbirth was associated with increased odds of internalizing symptoms from adolescence to adulthood. For male participants, the increase in odds was greater in a context of higher vs lower socioeconomic adversity, while for female participants, the increase in odds was greater in a context of lower vs higher socioeconomic adversity.

Meaning   These findings suggest that prevention of postnatal depression in LMIC settings may be associated with decreases in the prevalence of psychological problems in the next generation; such prevention may be maximized by considering individual differences by sex and exposure to socioeconomic adversity.

Importance   Few studies from low-and-middle income countries have investigated long-term associations between maternal postnatal depression and offspring internalizing (ie, depressive and anxiety) symptoms, and none have investigated interactions in this association.

Objective   To investigate the association between maternal postnatal depression and offspring internalizing symptoms from adolescence to adulthood and the interaction with exposure to socioeconomic adversity and with the child’s sex.

Design, Setting, and Participants   This secondary analysis used data from Birth to Twenty Plus (BT20+), a prospective birth cohort study of children born in Soweto, South Africa, and followed up until age 28 years. Data were collected from 1990 to 2018, and data were analyzed for this study from February 16 through December 15, 2020.

Exposures   Maternal postnatal depression self-reported by mothers 6 months after childbirth.

Main Outcomes and Measures   The main outcome was offspring internalizing symptoms, assessed at offspring ages 14 years, 22 years, and 28 years and modeled longitudinally. Participants with the highest probability of experiencing high internalizing symptoms (ie, those in the top 20% of the distribution) from age 14 to 28 years were categorized as belonging to the high internalizing symptoms trajectory (vs the low trajectory). Socioeconomic adversity was measured with an index (continuous variable) including low maternal education, household crowding, low assets, and low maternal age. This variable was further stratified into more than 1 SD above the mean index, more than 1 SD below the mean index, and from 1 SD below to 1 SD above the mean index to conduct subgroup analyses. Associations were investigated using multivariable regression models.

Results   Among 1087 participants born in Soweto, South Africa (543 [50.0%] male participants; 544 [50.0%] female participants), 118 individuals (10.8%) showed a high trajectory of internalizing symptoms from age 14 to 28 years vs 969 individuals (89.1%) with a low trajectory. Children exposed to maternal postnatal depression had statistically significantly increased odds of following the high trajectory (adjusted odds ratio [aOR] per 1-SD increase in maternal postnatal depression, 1.20; 95% CI, 1.02-1.41). This increase in odds differed by exposure to socioeconomic adversity and by child sex: for male participants, the increase in odds was greater in a context of higher vs lower socioeconomic adversity (eg, for >1 SD above the mean: aOR, 3.28; 95% CI, 1.06-10.14 vs for >1 SD below the mean: aOR, 0.98; 95% CI, 0.64-1.50; P for interaction = .12), while for female participants, the increase in odds was greater in a context of lower vs higher socioeconomic adversity (eg, for >1 SD below the mean: aOR, 1.82; 95 % CI, 1.12-2.98 vs for >1 SD above the mean: aOR, 0.59; 95 % CI, 0.30-1.17; P for interaction = .002) ( P for 3-way interaction = .003).

Conclusions and Relevance   This study found that postnatal depression was associated with higher odds of persistently increased internalizing symptoms among offspring from adolescence to adulthood in a middle-income country, with variation by socioeconomic adversity and sex. These findings suggest that better understanding of these associations is needed to implement targeted interventions and maximize the impact of public health initiatives aimed at breaking the intergenerational transmission of mental health problems.

The early home environment is associated with mental health outcomes across an individual’s lifespan. 1 Specifically, exposure to maternal depression has consistently been associated with offspring internalizing depressive and anxiety symptoms. 2 , 3 The prevalence of maternal perinatal (ie, antenatal or postnatal) depression is 11% to 13% among women in high-income countries 4 (HICs; according to World Bank definitions). 5 Prevalence rates are increased for women in low and middle income countries (LMICs; according to World Bank definitions), with a 2016 systematic review 1 reporting that 1 in 4 women presented with antenatal depression and 1 in 5 presented with postnatal depression. Despite increased rates of perinatal depression in LMICs, 6 it is a neglected area of research, with limited evidence on the short-term associations and long-term associations with child outcomes. Given this lack of study, women’s and children’s mental health problems within these contexts are largely unrecognized and untreated. 1 , 7 Indeed, the context within which perinatal depression and internalizing symptoms occur differ in LMICs, where children are more likely to be exposed to many risk factors, including poverty and high rates of violence, compared with HICs. Context-specific studies are therefore key to identifying and targeting potential interventions to prevent and reduce internalizing symptoms among offspring exposed to perinatal depression, as well as to ensure that interventions are tailored to the local context.

In HICs, studies have found that perinatal depression is associated with internalizing symptoms across childhood and adolescence 8 , 9 and that there is an interaction with individual and environmental characteristics for this association. At the individual level, 2 studies 3 , 8 found a greater increase in internalizing symptoms with perinatal depression among girls, while others find no evidence of sex differences. At the environmental level, studies report an interaction with socioeconomic adversity whereby children exposed to perinatal depression and low socioeconomic adversity have better mental health outcomes compared with children exposed to cumulative adversity (ie, perinatal depression and high socioeconomic adversity, including low levels of parental education and financial support). 2 , 3 , 10 Interactions with sex or socioeconomic adversity could suggest that different intervention approaches may be required to mitigate the association of maternal depression with child outcomes in boys vs girls and families from lower vs higher socioeconomic adversity contexts. 10 For example, in the Avon Longitudinal Study of Parents and Children in the UK, 11 for children exposed to the same level of perinatal depression, those experiencing greater socioeconomic adversity were more likely to experience increased rates of internalizing symptoms. That study did not explore the interaction with child’s sex. In the handful of studies that have been conducted in LMICs, 7 , 12 - 18 the pattern of associations between perinatal depression and children’s internalizing symptoms is generally similar to that found in HICs, including mixed evidence on the interaction with child’s sex. However, to our knowledge, no study to date has examined the interaction of socioeconomic adversity with maternal depression in the association with offspring internalizing symptoms in LMICs. This is acknowledged as one of the largest gaps in the current literature on perinatal depression and child outcomes in LMICs. 1 , 10

Studies suggest that the pattern of associations between socioeconomic factors and mental health in HICs is not the same as in LMICs. For example, a cross-national comparative study 19 of adults in HICs and LMICs found conflicting results in investigating the association between socioeconomic adversity and mental health. These findings highlight the importance of context-specific studies to understand how the interaction between socioeconomic adversities and mental health plays out in different sociocultural contexts. 10

In this study, we examined the interaction of socioeconomic adversity and postnatal depression in the association with offspring internalizing symptoms across adolescence and early adulthood in male and female participants in South Africa. Given mixed evidence from prior studies in LMICs, we had no a priori hypotheses concerning the interaction of child’s sex and socioeconomic adversity with postnatal depression in the association with offspring internalizing symptoms.

Ethical approval for this cohort study was obtained from the Committee for Research on Human Subjects at the University of the Witwatersrand in South Africa, and written informed consent was obtained from all participants. We adhered to the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for standard reporting in cohort studies.

This study draws on secondary data from the Birth to Twenty Plus (BT20+) study, a prospective birth cohort based in Soweto, a historically informal settlement in Johannesburg, South Africa. 20 The cohort enrolled all singleton children born during a 7-week period in 1990, with the aim of describing the associations between rapid urbanization and the physical and psychosocial development of children. 20 Women were pregnant and gave birth during an extremely volatile and violent time in South Africa’s history, both politically and socially. A sample of 3273 women was recruited, and they and their children have been followed up more than 22 times to offspring age 28 years (data collection from child’s birth in 1990 to 2018). Data have been collected on social and economic circumstances, family relationships, growth and health outcomes, and schooling and employment. Consensual agreement on the phrasing of questions was reached when different languages were required, with isiZulu, Sesotho, and English being the most commonly used languages. From participants’ age 15 years, data have been collected through audio-assisted computer methods and tablets. The sample in this study included 1087 participants with data on postnatal depression and offspring internalizing symptoms (≥1 measure collected per participant from ages 14-28 years). Participants who had data on postnatal depression alone or offspring internalizing symptoms alone were excluded from analyses. Because the analytical sample differed from the original cohort on several variables (ie, maternal age, schooling, household crowding, and family assets), inverse probability weighting was used in all analyses.

Postnatal maternal depression was assessed when children were age 6 months using the Pitt inventory. 21 This measure has been previously used in numerous studies in HICs and LMICs, including South Africa, for a period extending 20 years. 18 , 22 , 23 It correlates highly (ρ = 0.67) with other criterion standard measures of postnatal depression, such as the Edinburgh Postnatal Depression Scale. 24 This validated measure consists of 24 items (Cronbach α, 0.85) assessing current feelings and changes in mood. The inventory is scored on a 3-point scale (1 for yes, 0 for no, and missing for I don’t know). The total score was computed (range 0-24) and standardized.

Internalizing symptoms were assessed among children at ages 14 years, 22 years, and 28 years using validated self-report questionnaires, including common and age-appropriate anxiety and depression symptoms. At children’s age 14 years, we used 24 items from the Youth Self Report’s internalizing scale (Cronbach α, 0.86), a measure specifically designed for adolescents and developed by the Achenbach System of Empirically Based Assessment. 25 It has strong psychometric properties gathered from diverse cultural settings, 26 with the validity of the measure confirmed across multilingual and multicultural environments, 27 , 28 including South Africa. 29 The measure includes items such as “I am unhappy,” “I worry a lot,” and “I have headaches.” Items were answered on a 3-point scale (ie, 0 for not true, 1 for somewhat or sometimes true, and 2 for very or often true) in reference to the past 6 months. At participants’ age 22 years, we used 21 items from the General Health Questionnaire (GHQ-28; Cronbach α, 0.93) 30 somatic, anxiety and insomnia, and depression sections, including items such as “lost much sleep over worry,” “been feeling nervous or strung up all the time,” and “felt that life is entirely worthless.” Items were answered on a 4-point scale (ie, 0 for not at all, 1 for no more than usual, 2 for rather more than usual, and 3 for much more than usual) with reference to current or recent feelings. The GHQ-28 is associated with other widely used measures of mental health cross-culturally in HICs and LMICs 31 and has been used previously in South Africa. 32 At participants’ age 28 years, we used the World Health Organization (WHO) Self Reporting Questionnaire, 33 which shows strong validity compared with other commonly used measures of adult mental health, including in South African settings. 34 , 35 The scale includes binary items (ie, yes and no) assessing the presence of 20 symptoms experienced during the previous 30 days, such as, “Do you often have headaches?”, “Do you feel nervous, tense, or worried?”, and “Do you sleep badly?” (Cronbach α, 0.93). Given that these 3 measures have different scales, we dichotomized the measures and considered participants scoring at the top 20% of symptoms within each measure as having high levels of internalizing symptoms. This enabled us to harmonize the 3 measures and model them longitudinally, as described in a later section.

Drawing on Trude et al, 36 socioeconomic adversity in the early life environment was measured using 4 indicators: (1) poverty (measured as being below the third wealth quintiles derived from a site-specific list of assets [ie, television, refrigerator, car, washing machine, and phone] according to the widely used and culturally validated methodology of Filmer and Pritchett 37 - 39 ), (2) low maternal education (ie, ≤the third quartile of the distribution), (3) low maternal age (ie, <age 18 years at childbirth), and (4) household crowding (ie, >3 people per room). These cutoffs are based on international standards determined by WHO. 40 The socioeconomic adversity index was calculated using a factor analysis model and standardized (ie, mean [SD], 0 [1]) (eTable 1 in the Supplement ). Adversity was stratified as high and low (ie, those >1 SD above or >1 SD below the mean index, respectively), with individuals from 1 SD below to 1 SD above the mean as the reference group.

We used group-based trajectory modeling to identify groups of children following distinct developmental trajectories of internalizing symptoms from adolescence to adulthood. 41 We modeled the probability of having high internalizing symptoms (ie, scoring in the top 20% of scores) at each point. The advantage of this method is that it allows one to identify individuals following trajectories of internalizing symptoms within a population without establishing arbitrary cutoffs. Additionally, this method relies on maximum likelihood estimation, enabling us to use all available information in the data instead of excluding participants with missing data. 41 We therefore used data from all participants who reported internalizing symptoms on at least 1 occasion. We also conducted sensitivity analyses in which trajectories were estimated for participants with data available in 2 of 3 assessments.

We used logistic regression analysis to estimate the association between postnatal depression and trajectories of offspring internalizing symptoms. To investigate differential odds increases between postnatal depression and offspring internalizing symptoms by socioeconomic adversity, we tested the interaction between postnatal depression and socioeconomic adversity index score. All models were adjusted for child sex, birth weight (ie, <2.5 kg vs ≥2.5 kg), and birth order (ie, first, second, third or later born). Additionally, we systematically tested the interaction with child sex to investigate whether odds changes were similar for male participants vs female participants.

P values were evaluated using 2-sided 2-sample t tests and χ 2 tests, and significance was set at P  < .05. Data were analyzed using R statistical software version 3.6 (R Project for Statistical Computing) from February 16 through December 15, 2020.

Among 1087 mother-child dyads, whose characteristics are presented in the Table , there were 544 (50.0%) girls and 543 (50.0%) boys. A higher percentage of boys were born to a mother aged less than 18 years (43 boys [7.9%] vs 39 girls [7.2%]; P  = .02). There were no other statistically significant differences in sample characteristics by sex. Across male and female participants, similar mean (SD) levels of postnatal depression scores (0.001 [1.032] vs −0.001 [0.971]) and socioeconomic adversity scores (−0.002 [0.618] vs −0.026 [0.601]) were observed. Features of the socioeconomic environment were not associated with maternal postnatal depression. Internalizing symptoms showed consistency across time: adolescents with high symptom levels at age 14 years were 2-fold as likely to have high symptom levels at age 22 years (odds ratio [OR], 2.34; 95% CI, 1.75-3.13) and age 28 years (OR, 2.03; 95% CI, 1.48-2.80), and young adults with high symptoms at age 22 years were more than 3-fold as likely to have high symptoms at age 28 years (OR, 3.78; 95% CI, 2.92-4.89).

Group-based trajectory modeling identified 2 trajectories ( Figure 1 ): a high internalizing symptoms trajectory, clustering 118 individuals (10.8%) with high levels of internalizing symptoms from adolescence to adulthood, and a low internalizing symptoms trajectory, clustering 969 individuals (89.1%) with low levels of internalizing symptoms in this period. The selected model provided the best fit in terms of classification accuracy, as assessed by the mean posterior probability of class membership, entropy (0.83, with values >0.70 indicating good classification accuracy), and best fit compared with models with 1 or more than 2 trajectories, as assessed with the bayesian information criterion (BIC; best fitting model is the 1 minimizing BIC; 1-trajectory model: BIC = −1209.58; 2-trajectory model: BIC = −1188.49; 3-trajectory model: BIC = −1196.71; 4-trajectory model: BIC = −1208.40). The distribution of male and female participants differed by trajectory, with an overrepresentation of female participants in the high internalizing symptoms trajectory (89 female participants [74.4%]) compared with the low trajectory (455 female participants [47.0%]). The difference in mean (SD) socioeconomic adversity between participants in high vs low internalizing symptoms trajectories was larger for male participants (0.32 [1.00] vs −0.13 [1.00]) compared with female participants (0.04 [1.00] vs −0.06 [1.00]). However, similar mean (SD) maternal postnatal depression levels were found for participants in the high vs low internalizing symptoms trajectories among male participants (0.20 [0.92] vs 0.05 [1.00]) and female participants (0.15 [1.00] vs 0.02 [1.00]).

The adjusted OR (aOR) for the association between postnatal depression and high offspring trajectories of internalizing symptoms was 1.20 per 1-SD increase in postnatal depression (95 % CI, 1.02-1.41). This suggests that children of mothers with increased postnatal depression symptoms were more likely to follow the trajectory with high internalizing symptoms compared with children of mothers with low postnatal depression symptoms (ie, 20% higher odds for each 1-SD increase in postnatal depression).

In interaction analyses, this increase in odds was not homogenous across the sample but varied by level of socioeconomic adversity and child sex (3-way interaction: log[aOR], −0.57; SE, 0.19; P  = .003). See eTable 2 and eFigure 1 in the Supplement for marginal predicted probabilities and eFigure 2 in the Supplement for interactions using each indicator of the socioeconomic adversity index. As represented in Figure 2 , we found that, for female participants, the increase in odds of belonging to the high trajectory of offspring internalizing symptoms per 1-SD increase in maternal postnatal depression was greater among individuals exposed to lower levels of socioeconomic adversity compared with those exposed to higher levels (2-way interaction between maternal depression and socioeconomic adversity index among female participants: log[aOR] = −0.32, SE = 0.10; P  = .002), while the opposite trend was observed for male participants (2-way interaction between maternal depression and socioeconomic adversity index among male participants: log[aOR] = 0.25; SE = 0.16; P  = .12).

We conducted stratified analyses by levels of socioeconomic adversity index score to better understand the increase in odds of the high trajectory of internalizing symptoms associated with each 1-SD increase in postnatal depression. As shown in Figure 3 , the increase in odds was greater for the lowest stratum of socioeconomic adversity (ie, >1 SD below the mean of the index) vs the highest stratum (ie, >1 SD above the mean of the index) among female participants (aOR, 1.82; 95% CI, 1.12-2.98 vs aOR, 0.59; 95% CI, 0.30-1.17) but not among male participants. In the highest stratum of socioeconomic adversity compared with the lowest stratum, there was a greater increase in odds among male participants (aOR, 3.28; 95% CI, 1.06-10.14 vs aOR, 0.98; 95 % CI, 0.64-1.50) but not among female participants.

To our knowledge, this cohort study is the first study to investigate the association between exposure to postnatal depression and offspring internalizing symptoms across adolescence and adulthood in the South African context. We found that exposure to postnatal depression in the first 6 months of life was associated with internalizing symptoms through adolescence and young adulthood up to age 28 years. Importantly, we found an interaction of child sex and of socioeconomic adversity with maternal depression in this association. Specifically, we found that, for male participants, the increase in odds of belonging to the high offspring internalizing symptoms trajectory when the mother had higher postnatal depression was greater in a context of higher compared with lower socioeconomic adversity; conversely, for female participants, the increase in odds was greater in a context of lower compared with higher socioeconomic adversity.

Prior studies in LMICs found that exposure to maternal depression early in life was associated with negative socioemotional outcomes during childhood. 7 , 42 - 44 This includes 2 previous studies using BT20+ data, which reported that children exposed to postnatal depression (measured at child’s age 6 months) were more likely to experience psychological distress, inclusive of internalizing symptoms, in early childhood (ie, age 2 years) 13 and middle childhood (ie, age 10 years) 18 compared with those unexposed as infants. Therefore, our findings extend current knowledge by showing that the association between postnatal depression and internalizing symptoms is discernible during the first 3 decades of life. To date, this is 1 of the longest follow-up studies of this kind and the longest follow up in a LMIC. This finding is in line with previous studies 11 , 15 , 17 , 45 - 50 in HICs and LMICs reporting a persistent association between maternal depression and offspring mental health in adolescence and adulthood. The Avon Longitudinal Study of Parents and Children in the UK, 11 which was based on population samples, reported associations similar in size to those reported in our study.

Several mechanisms may explain the observed associations. 3 From a biological perspective, genetic liability for mental health problems may account for the heightened vulnerability to internalizing symptoms among offspring of depressed mothers. 51 Other biological mechanisms that may explain the association between postnatal depression and offspring outcomes include epigenetic modifications of gene expression and changes in the glucocorticoid, oxytocin, estrogen, and immune systems. 51 From an environmental point of view, postnatal depression has been found to be associated with changes in maternal responsiveness toward her child, impaired ability to respond adequately to infant cues, inhibited maternal support and protection, and reduced maternal perceptions of self-efficacy. 10 , 52 , 53 All of these outcomes have the potential to compromise the quality of parenting, as shown in a recent meta-analysis that found an interaction between maternal parenting behaviors and the association between perinatal depression and mental health outcomes across childhood and adolescence. 53 Maternal mental health problems have also been associated with increased risk of family conflict and domestic violence, which, independently and jointly, are risk factors associated with poor mental health among offspring. 54 Additionally, there is evidence that continued exposure to maternal depression during childhood, as opposed to limited or intermittent exposure, is associated with poor outcomes among offspring. 55 , 56 It is worth noting that evidence for such mechanisms is available mainly for short-term associations and in HIC settings. Future studies should therefore further clarify whether and how these mechanisms explain associations that persist until adulthood in LMICs. 10

In line with previous studies, we found an interaction between exposure to socioeconomic adversity, which is associated with parental mental health problems and limitations in a parent’s ability to provide for their child, 3 , 53 and postnatal depression in the association with offspring internalizing symptoms. However, contrary to results from previous studies, 11 , 47 which did not test for or did not observe sex differences, we found that the interaction was different among male participants (who had greater increases in odds of internalizing symptoms if exposed to maternal depression in a higher socioeconomic adversity context) vs female participants (who had greater increases in odds of internalizing symptoms if exposed to maternal depression in a lower socioeconomic adversity context). Understanding such differential interactions by sex, socioeconomic adversity, and maternal postnatal depression in South Africa would require additional investigations, such as qualitative in-depth studies considering social and cultural contexts in which children develop. Factors that may be associated with these outcomes include childcare practices (eg, mothers with very low levels of education may be more dependent on and receive help with raising their child from members of the extended family, including informal nonparental care from family members, 57 which may be associated with decreased exposure to postnatal depression for those children). Additional factors may include the societal value of having a male or female child (including family expectations for child education and future social roles) 58 and sex differences in reactivity to stress during childhood. 59 Shedding light on how socioeconomic variations and individual characteristics interact in the association of postnatal depression with outcomes among children is a key step toward implementing personalized interventions and maximizing the impact of public health policy.

This study has several limitations. First, attrition was substantial, although comparable with that of other longitudinal cohort studies. 60 , 61 Attrition in the BT20+, which has been described elsewhere, 20 is due to a combination of factors, including temporary and permanent migration, which may compromise generalizability of the findings to all of South Africa’s diverse population and to people living at the higher end of the socioeconomic scale. To address biases due to differential attrition, we used inverse probability weighting, but many factors potentially associated with attrition may not have been considered. Furthermore, the analysis sample was not representative of the country’s general population, as is the case with other longitudinal birth cohorts. 60 , 61 Second, assessment of internalizing symptoms among offspring relied on 3 different questionnaires. Although they all measured the same construct, broadly defined as internalizing symptoms, measurement differences may have introduced bias. Relatedly, these measures required dichotomization to homogenize their distribution for our longitudinal model, which may have led to a loss of information. Nevertheless, the questionnaires used were appropriate for the specific age categories analyzed (ie, adolescence, early adulthood, and adulthood). Third, we assessed postnatal depression once and were therefore unable to account for variation in depressive symptoms in the first postnatal year. Fourth, we used a measure of depressive symptoms and not a clinical diagnosis, which prevents us from generalizing our results to clinical populations. Nevertheless, the Pitt inventory is a validated measure of depressive symptoms in general population samples that have relatively high prevalence of subclinical symptoms.

This study, based on longitudinal data from South Africa, found that exposure to postnatal depression was associated with higher odds of internalizing symptoms among offspring persisting into adulthood, with important variations in odds increase by level of socioeconomic adversity and child sex. These findings stress the association between maternal and child emotional well-being, specifically that the emotional well-being of mothers is associated with the quality of children’s emotional development. This is true even in contexts, like that in this study, in which risk factors associated with mental health problems, including socioeconomic adversity, are widespread. Our findings suggest the need for further examination of the mechanisms of the association between maternal depression and offspring outcomes, including the interaction of socioeconomic adversity and child’s sex, in LMIC contexts. Such research may inform context-specific public policy aiming to promote maternal psychological well-being and child and adolescent development.

Accepted for Publication: June 12, 2021.

Published: August 19, 2021. doi:10.1001/jamanetworkopen.2021.21667

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2021 Orri M et al. JAMA Network Open .

Corresponding Author: Massimiliano Orri, PhD, McGill Group for Suicide Studies, Douglas Mental Health University Institute, Department of Psychiatry, McGill University, 6875 LaSalle Blvd, Frank B. Common Pavilion, Montreal, QC H4H 1R3, Canada ( [email protected] ).

Author Contributions: Drs Orri and Richter had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Besharati and Ahun provided equal contributions.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Orri.

Obtained funding: Richter.

Administrative, technical, or material support: Besharati, Ahun, Richter.

Supervision: Richter.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Department of Science and Innovation-National Research Foundation Centre of Excellence in Human Development at the University of the Witwatersrand in Johannesburg, the Republic of South Africa. This study was funded by a grant from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement no. 793396 (Dr Orri). Dr Ahun was funded by a Vanier Canada Graduate Scholarship from the Canada Social Sciences and Humanities Research Council. The Birth to Twenty Plus sample has been funded by the Wellcome Trust, South African Medical Research Council, Human Sciences Research Council, and University of the Witwatersrand, among others. The 28-year data collection was funded by opportunity fund 1164115 from the Bill and Melinda Gates Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: Dr Richter is the principal investigator of the Birth to Twenty Plus cohort and supervised the overall study.

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Towards an understanding of gps' viewpoint on diagnosing postnatal depression in general practice: a small-scale realist evaluation.

BACKGROUND: Less than half of postnatal depression cases are identified in routine clinical assessment. Guidelines and current literature suggest that general practitioners (GPs) may have an opportunistic role in detecting postnatal depression due to their early contact and existing rapport with many new mothers. There is limited research on the diagnostic approaches chosen by GPs in different GP-patient contexts. Our small-scale study evaluates the thought processes of seven GPs based in ...

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Research Article

The bidirectional association between premenstrual disorders and perinatal depression: A nationwide register-based study from Sweden

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (QY); [email protected] (DL)

Affiliation Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden

Roles Writing – review & editing

Affiliations Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America, Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America

Roles Methodology, Supervision, Validation, Writing – review & editing

Affiliation Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

Roles Resources, Supervision, Writing – review & editing

Roles Data curation, Methodology, Resources, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing – review & editing

Affiliations Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden, Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America, Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland

Roles Conceptualization, Data curation, Funding acquisition, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – review & editing

• Qian Yang, 
• Emma Bränn, 
• Elizabeth R. Bertone- Johnson, 
• Arvid Sjölander, 
• Fang Fang, 
• Anna Sara Oberg, 
• Unnur A. Valdimarsdóttir, 

• Published: March 28, 2024
• https://doi.org/10.1371/journal.pmed.1004363
• Peer Review
• Reader Comments

Premenstrual disorders (PMDs) and perinatal depression (PND) share symptomology and the timing of symptoms of both conditions coincide with natural hormonal fluctuations, which may indicate a shared etiology. Yet, there is a notable absence of prospective data on the potential bidirectional association between these conditions, which is crucial for guiding clinical management. Using the Swedish nationwide registers with prospectively collected data, we aimed to investigate the bidirectional association between PMDs and PND.

Methods and findings

With 1,803,309 singleton pregnancies of 1,041,419 women recorded in the Swedish Medical Birth Register during 2001 to 2018, we conducted a nested case-control study to examine the risk of PND following PMDs, which is equivalent to a cohort study, and transitioned that design into a matched cohort study with onward follow-up to simulate a prospective study design and examine the risk of PMDs after PND (within the same study population). Incident PND and PMDs were identified through clinical diagnoses or prescribed medications. We randomly selected 10 pregnant women without PND, individually matched to each PND case on maternal age and calendar year using incidence density sampling (N: 84,949: 849,482). We (1) calculated odds ratio (OR) and 95% confidence intervals (CIs) of PMDs using conditional logistic regression in the nested case-control study. Demographic factors (country of birth, educational level, region of residency, and cohabitation status) were adjusted for. We (2) calculated the hazard ratio (HR) and 95% CIs of PMDs subsequent to PND using stratified Cox regression in the matched cohort study. Smoking, BMI, parity, and history of psychiatric disorders were further controlled for, in addition to demographic factors. Pregnancies from full sisters of PND cases were identified for sibling comparison, which contrasts the risk within each set of full sisters discordant on PND. In the nested case-control study, we identified 2,488 PMDs (2.9%) before pregnancy among women with PND and 5,199 (0.6%) among controls. PMDs were associated with a higher risk of subsequent PND (OR 4.76, 95% CI [4.52,5.01]; p < 0.001). In the matched cohort with a mean follow-up of 7.40 years, we identified 4,227 newly diagnosed PMDs among women with PND (incidence rate (IR) 7.6/1,000 person-years) and 21,326 among controls (IR 3.8). Compared to their matched controls, women with PND were at higher risk of subsequent PMDs (HR 1.81, 95% CI [1.74,1.88]; p < 0.001). The bidirectional association was noted for both prenatal and postnatal depression and was stronger among women without history of psychiatric disorders ( p for interaction < 0.001). Sibling comparison showed somewhat attenuated, yet statistically significant, bidirectional associations. The main limitation of this study was that our findings, based on clinical diagnoses recorded in registers, may not generalize well to women with mild PMDs or PND.

Conclusions

In this study, we observed a bidirectional association between PMDs and PND. These findings suggest that a history of PMDs can inform PND susceptibility and vice versa and lend support to the shared etiology between both disorders.

Author summary

Why was this study done.

• Perinatal depression (PND) and premenstrual disorders (PMDs) share symptomology (e.g., feeling depressed), and the timing of symptom onset of both conditions coincides with natural hormonal fluctuations.
• Prospective data are lacking to study the potential bidirectional association between these conditions, which can guide clinical management.

What did the researchers do and find?

• We conducted a nested case-control study and transitioned that design into a matched cohort study with onward follow-up to simulate a prospective study design.
• Among approximately 1.8 million singleton pregnancies in Sweden during 2001 to 2018, we identified 84,949 women with PND and 849,482 unaffected women, individually matched on age and calendar year. Pregnancies from full sisters of women with PND were also identified for sibling comparison.
• Among women with PND, 2.9% had PMDs before pregnancy, in contrast to 0.6% among matched unaffected women. PMDs were associated with a nearly 5 times higher risk of subsequent PND. In the matched cohort with a mean follow-up of 6.90 years, women with PND had almost 2 times higher risk of subsequent PMDs, compared to matched unaffected women.
• The bidirectional association between PMDs and PND was noted for both prenatal and postnatal depression, regardless of history of psychiatric disorders, and also in sibling comparison.

What do these findings mean?

• These findings suggest that a history of PMDs can inform PND susceptibility and vice versa.
• The main limitation of this study was that our findings, based on clinical diagnoses or prescribed medications, may not generalize well to women with mild PMDs or PND.

Citation: Yang Q, Bränn E, Bertone- Johnson ER, Sjölander A, Fang F, Oberg AS, et al. (2024) The bidirectional association between premenstrual disorders and perinatal depression: A nationwide register-based study from Sweden. PLoS Med 21(3): e1004363. https://doi.org/10.1371/journal.pmed.1004363

Received: May 22, 2023; Accepted: February 19, 2024; Published: March 28, 2024

Copyright: © 2024 Yang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data are from the Swedish national healthcare registers. Data cannot be put into a public data repository according to Swedish law but are available by applying through Statistics Sweden or the Swedish National Board of Health and Welfare. Detailed information on data application can be found in the following links: https://www.scb.se/vara-tjanster/bestalla-mikrodata/ and https://bestalladata.socialstyrelsen.se/ .

Funding: The work was supported by the Chinese Scholarship Council (No. 201700260289 to QY), the Swedish Research Council for Health, Working Life and Welfare (FORTE) (No. 2020-00971 and 2023-00399 to DL), the Swedish Research Council (Vetenskapsrådet) (No. 2020-01003 to DL), Karolinska Institutet Strategic Research Area in Epidemiology and Biostatistics (grant to DL), Karolinska Institutet SFOepi Junior Scholar Grant (to DL) and the Icelandic Research Fund (No. 218274-051 to UAV). The funders had no role in study design, data collection and analysis, preparation of the manuscript or decision to publish.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; CI, confidence interval; HR, hazard ratio; IR, incidence rate; MBR, Medical Birth Register; MGR, Multi-Generation Registers; OR, odds ratio; PMD, premenstrual disorder; PMDD, premenstrual dysphoric disorder; PMS, premenstrual syndrome; PND, perinatal depression

Introduction

Premenopausal women experience natural hormonal fluctuations associated with various life events, such as puberty, menstrual cycle, pregnancy, and menopause. Some women are more likely to develop or manifest mood symptoms during these events. For instance, perinatal depression (PND) is characterized by depressive symptoms occurring during pregnancy and up to 12 months after delivery and affects 11% of mothers globally [ 1 ]. PND has been positively associated with maternal suicidal behavior and has a negative influence on mother–infant bonding [ 2 ]. Similarly, premenstrual disorders (PMDs) are characterized by somatic and/or psychological symptoms that recur in luteal phase. PMDs cause significant functional impairment [ 3 – 5 ]. PMDs affect 20% to 30% of women of reproductive age [ 4 ], and about 5% to 8% of women suffer from severe symptomology [ 3 ]. PMDs are associated with increased risks of suicidal behavior and accidents [ 6 ].

PND and PMDs share symptomology (e.g., feeling depressed) and the timing of symptom onset of both conditions coincides with natural hormonal fluctuations [ 7 , 8 ]. Therefore, it has been postulated that these disorders may have common etiology and shared risk factors [ 9 ]. This hypothesis is supported by 2 recent systematic reviews showing that women with PND were more likely to have a history of PMDs [ 10 , 11 ]. However, existing studies relied on retrospectively collected on data premenstrual symptoms during or after pregnancy, which might be prone to recall bias and thereby biased results [ 12 , 13 ]. Moreover, the community- or clinic-based sampling in previous studies may have introduced significant selection bias [ 14 ]. Premenstrual symptoms can worsen after pregnancy due to an escalated abnormal response to hormonal changes in relation to pregnancy [ 15 ]. It is thus plausible that women with PND are at risk for subsequent PMDs. However, few studies with a relatively small sample size have examined this hypothesis by comparing proportions without adjustment for confounders and generated inconsistent results [ 16 – 18 ].

Taken together, without prospective evidence, it remains unclear whether women with PMDs have an increased risk of developing PND when becoming pregnant or after giving birth and vice versa. Using the Swedish nationwide registers with prospectively collected data, we aimed to investigate the bidirectional association between PMDs and PND. To study the bidirectional association in the same population effectively, we conducted a nested case-control study, a design inherently equivalent to a cohort study [ 19 ]. To examine the risk of PND following PMDs in a manner that simulates a prospective approach, we then transitioned this design into a matched cohort study to assess the risk of PMDs after PND. We further employed sibling comparisons to account for shared genetic and familial environmental risk factors for both disorders.

Data sources

Based on the Medical Birth Register (MBR), we identified 1,803,309 singleton pregnancies from 1,041,419 women during 2001 to 2018. The MBR covers virtually all births in Sweden since 1973, with rich information prospectively collected from prenatal, delivery, and neonatal care [ 20 , 21 ]. Multiple births ( n = 51,824), pregnancies after PND diagnosis ( n = 34,790), pregnancies from women who emigrated before 2001 ( n = 952), or pregnancies before age 15 or after age 52 ( n = 383) were excluded. The Patient Register, Prescribed Drug Register, Migration Register, Causes of Death Register, and Multi-Generation Register (MGR) were cross-linked using the unique personal identification number. The Patient Register collects information on all inpatient admissions for psychiatric care since 1973 and for somatic diseases since 1987 and >80% outpatient visits since 2001 [ 22 ]. The Prescribed Drug Register contains information on medications redeemed from all pharmacies in Sweden since July 2005 [ 23 ]. MGR contains information on familial links for individuals born from 1932 onward [ 24 ].

Ascertainment of PND

In line with previous studies [ 25 ], we identified PND from the date obtained by subtracting gestational age from the delivery date till 1 year postpartum, using the Swedish version of International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes (F32, F33, and F53.0) recorded in the MBR and Patient Register. According to the Swedish National Board of Health and Welfare, F32 and F33 are ICD-10 codes used to identify depression in Swedish healthcare registers according to the Swedish National Board of Health and Welfare [ 26 ] and have been reported to have high validity in the Swedish population (κ of 0·32; 88% full agreement with gold standard) [ 27 ]. F53.0 identifies perinatal depression not captured elsewhere [ 26 ]. Gestational age was, whenever possible, estimated according to ultrasound, which has been offered to all pregnant women in Sweden since 1990 and is performed for 95% of all pregnancies [ 28 ]. Nearly half of mental health problems are managed in primary care in Sweden [ 29 ]. Therefore, any prescription of antidepressants (ATC code N06A) was also considered as a proxy for PND. Antidepressants are commonly prescribed for PMDs as first-line treatment [ 30 ]. Prescriptions of antidepressants with an indication for PMDs, as described elsewhere [ 6 ], were not considered. The date of PND diagnosis was defined as the date of receiving a clinical diagnosis or filling a prescription of antidepressants, whichever came first. Since the MBR does not record the date of diagnosis and/or drug use, the median date of pregnancy was assigned as diagnosis date for those identified through MBR. Perinatal depression was then subcategorized into prenatal and postnatal depression using delivery date as cutoff point.

Ascertainment of PMDs

Clinical diagnoses of PMDs were retrieved from the Patient Register (ICD-10 code N943). PMDs include premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). In practice, PMS is often diagnosed based on criteria similar to the American College of Obstetricians and Gynecologists (ACOG) criteria [ 31 ], and PMDD is diagnosed in accordance with diagnostic criteria described in DSM-5 [ 32 ]. According to the Swedish guidelines, prospective daily symptom ratings for at least 2 consecutive menstrual cycles are required [ 33 ]. To capture diagnoses made in primary care, we identified all prescriptions of antidepressants (ATC codes N06AA, N06AB, and N06AX) and contraceptives (G02B and G03A) with a specified clinical indication of PMDs from the Prescribed Drug Register. Indications of PMDs were specified by the prescribers as free-text and identified with key word recognition, as described previously [ 6 ].

Study design

We identified 84,949 incident cases of PND, including 47,424 cases of prenatal depression and 37,525 cases of postnatal depression. Using incidence density sampling, 10 controls that were free from PND at the time when the matched case was diagnosed were randomly selected for each case. Controls were matched on gestational age for prenatal depression cases and matched on postnatal day for postnatal depression cases, together with maternal age ( n = 849,482). To effectively examine the bidirectional association between PMDs and PND within the same study population, we conducted a nested case-control study, a design inherently equivalent to a cohort study [ 19 ], identifying all pregnancies, corresponding PNDs and previous history of any indications for PMDs to examine the risk of PND following PMDs in a manner that simulates a prospective approach. We then transitioned this design into a matched cohort with onward follow-up of index PNDs and control pregnancies, enabling us to efficiently assess the risk of PMDs after PND within the same study population. The matching date was used as the index date. Women who had PMDs before their index date were excluded ( n = 7,687) and, as they were not at risk for incident PMD diagnosis. All women were then followed from 6 months after delivery (by when over 90% of Swedish women had stopped complete breastfeeding) [ 34 ] or the index date, whichever came later, until age 52, emigration, PMD diagnosis, or end of follow-up, whichever came first. During the follow-up, we observed 500 deaths in PND group and 1,559 deaths in matched controls.

The study design is illustrated in S1 Fig . The study was approved by the Regional Ethics Review Board in Stockholm (No. 2018-1515/31). Written informed consent is waived for register-based studies by Swedish law. This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline ( S1 Checklist ).

Information on the following covariates were retrieved: demographics (maternal age, country of birth, cohabitation status, region of residence, and educational level), smoking 3 months before the pregnancy, BMI in early pregnancy, parity, history of psychiatric disorders before pregnancy, and pregnancy complications and adverse outcomes including hypertensive and diabetic diseases, preterm birth (gestational week <37 weeks), stillbirth, low birth weight (birth weight<2,500 grams), congenital malformations of the offspring, and neonatal death of the offspring (death within 28 days of birth). Data origin and rational of the choice of covariates are described in S1 Methods . ICD codes are summarized in S1 Table , and categorization for covariates are presented in Table 1 . Missing values in covariates were coded as unknown for adjustment.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pmed.1004363.t001

Statistical analysis

We firstly compared the distributions of characteristics between PND cases and their matched controls.

PMDs and subsequent risk of PND.

In the nested case-control study, we calculated the percentage of PMDs before pregnancy for PND cases and controls separately and estimated odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression. The nested case–control analysis, by design, is equivalent to the analysis using full cohort (i.e., assessing the incidence of PND subsequent to PMDs). Using incidence density sampling for individual matching, the estimate OR can be interpreted as hazard ratio (HR) of PND, comparing women with and without PMDs before pregnancy [ 19 ]. This analysis was repeated separately for prenatal and postnatal depression, and PND diagnosed in different time windows [first trimester (within 13 gestational weeks) or second to third trimester for prenatal depression, and 0 to 3, 4 to 6, or 7 to 12 months after delivery for postnatal depression].

Both PMDs and PND are correlated with depression and other psychiatric disorders [ 35 , 36 ]. An interaction term between history of psychiatric disorders and PND was added to explore potential effect modification. Because parity is associated with many pregnancy complications and outcomes [ 37 ], we performed separate analyses for primi- and multiparous women. To explore effect modification by maternal age and calendar year, we also conducted stratified analysis by maternal age (categorized into 15 to 30 and 31 to 52) and calendar year at pregnancy.

PND and subsequent risk of PMDs.

In the matched cohort study, we calculated the incidence rate (IR) of PMDs among PND cases and matched controls and HRs and 95% CIs of PMDs using Cox regression (attained age as the underlying time scale and matching sets as strata). The proportional hazard assumption was deemed reasonable by inspecting the Schoenfeld residuals. Consistent with the nested case-control analyses, we performed analyses by PND subtype (pre- and postnatal depression and PND diagnosed in different time windows) and other stratification analyses.

Adjustment.

Model 1 accounted for the matching variables and Model 2 accounted for other demographic factors (country of birth, educational level, region of residency, and cohabitation status). In Model 3, smoking, BMI, parity, and history of psychiatric disorders were further controlled for. We considered Model 3 as the primary for the matched cohort study and Model 2 for the nested case-control study since these covariates were instead possible mediators in this scenario.

Sibling analysis.

PMDs and PND may have shared risk factors, such as poor support from family members and genetic factors [ 10 , 11 ], which would confound the studied associations. Sibling comparison contrasts the risk within each set of full sisters discordant on PND and inherently controls for unmeasured confounders shared between full sisters [ 38 ]. Briefly, all pregnancies from PND cases and their full sisters were identified through MBR linked to MGR. In total, 56,941 pregnancies from 40,665 full sisters (18,869 PND cases) were included. We examined the bidirectional association using conditional logistic regression and stratified Cox regression.

Additional analyses.

We limited the analysis to (1) PMDs with at least 2 specialists’ PMD diagnoses ≥28 days apart to test the validity of PMD diagnosis; (2) PND identified through clinical diagnosis alone to reduce misclassification by using dispensation of antidepressants; and (3) women without severe pregnancy complications or adverse delivery outcomes since they might confound or mediate the studied associations through chronic stress associated with such events [ 39 ]. Due to lack of individual-level data on return of postpartum menstruation, we performed a sensitivity analysis of cohort follow-up starting from 2, 3, or 12 months postpartum.

Data were prepared in SAS statistical software version 9.4 (SAS Institute, Cary, NC) and analyzed in Stata 15.1 (STATA, College Station, TX). The statistical significance was set at the nominal two-sided 5% level.

Characteristics

The median age was 30.71 at PND diagnosis. Compared to the controls, women with PND were less educated, were more likely to be born in Sweden, live alone and in South Sweden, had a higher BMI, were more likely to smoke, and have been diagnosed with psychiatric disorder before the pregnancy (all p -values < 0.001; Table 1 ). They were also more likely to be primiparous, deliver through cesarean section, and experience pregnancy complications and adverse pregnancy and birth outcomes (all p -values < 0.001; Table 1 ).

PMDs and subsequent risk of PND

We identified 7,687 women with PMDs before pregnancy (2,488 among women with PND) in the nested case-control study. PMDs were associated with a higher risk of subsequent PND (OR 4.98, 95% CI [4.74,5.23]; p < 0.001). Additional adjustment of demographic factors including country of birth, educational level, region of residence, and cohabitation status slightly attenuated the observed association (OR 4.76, 95% CI [4.52,5.01]; p < 0.001) ( Table 2 ). The association was observed for both prenatal (OR 4.58, 95% CI [4.28,4.90]; p < 0.001) and postnatal (OR 5.03, 95% CI [4.65,5.45]; p < 0.001) depression. Moreover, the association remained robust across different pre-/postnatal phases; the OR was lower for prenatal depression diagnosed during first trimester than for those diagnosed later during pregnancy and lower for postnatal depression within 6 months after delivery than those diagnosed during 7 to 12 months ( Table 2 ). Attenuated but statistically significant results were observed after adjusting for potential mediators including history of psychiatric disorders ( S2 Table ).

https://doi.org/10.1371/journal.pmed.1004363.t002

In the stratified analysis, an association between PMDs and subsequent PND was observed regardless of previous history of psychiatric disorders and was stronger among women without such history ( p for interaction < 0.001) ( Table 3 ). The association was stronger among multiparous than primiparous women and was comparable across maternal age and calendar year groups ( S3 Table ).

https://doi.org/10.1371/journal.pmed.1004363.t003

PND and subsequent risk of PMDs

During a mean follow-up of 6.90 years (standardized deviation 4.31, range 0.003 to 17.50) from 6 months postpartum onwards, we identified 25,553 newly diagnosed cases of PMDs (4,227 among women with PND) in the matched cohort study. Compared to their matched controls, women with PND were at higher risk of PMDs (HR 2.00, 95% CI [1.93,2.07]; p < 0.001). Adjustment for pregnancy characteristics, history of psychiatric disorders, together with demographic factors slightly attenuated the association (HR 1.81, 95% CI [1.74,1.88]; p < 0.001) ( Table 4 ). Estimated HRs were 1.67, 95% CI [1.58,1.76]; p < 0.001 for prenatal and 1.98, 95% CI [1.87,2.09]; p < 0.001 for postnatal depression. Similar associations were found across time windows during pregnancy and after delivery ( Table 4 ).

https://doi.org/10.1371/journal.pmed.1004363.t004

The association between PND and subsequent PMDs was stronger among women without a history of psychiatric disorder in the stratified analysis ( p for interaction < 0.001) ( Table 5 ). The association did not differ by parity and calendar year and was somewhat greater among women aged 31 to 52 years at pregnancy ( S4 Table ).

https://doi.org/10.1371/journal.pmed.1004363.t005

Additional analyses

Largely comparable bidirectional associations between PMDs and PND were observed in the sibling comparison, although results were somewhat attenuated compared to the population comparison ( Table 6 ).

https://doi.org/10.1371/journal.pmed.1004363.t006

In both study designs, robust bidirectional associations were observed when restricting to (1) women without pregnancy complications or adverse outcomes; (2) PMDs with 2 specialists’ diagnoses ≥28 days apart; and (3) PND ascertained through clinical diagnosis ( S5 Table ). Moreover, similar results were observed with different start of follow-up in the cohort study ( S6 Table ).

In the present study based on data from Swedish national registers, we found a bidirectional link between premenstrual disorders and perinatal depression, which was pronounced for prenatal and postnatal depression and slightly stronger for postnatal depression. The bidirectional association was verified among women without a history of psychiatric disorders. These findings were corroborated, despite the attenuation, in the sibling comparison, which controls for familial environmental and genetic factors.

Previous studies have used data on history of PMDs retrospectively collected during or after pregnancy, which might be vulnerable to recall bias and systematic error [ 12 , 13 ]. Taking advantage of prospectively collected data in Swedish healthcare registers, the study is the first, to our knowledge, to demonstrate a positive association between PMDs and subsequent risk of PND. Moreover, previous studies exclusively focused on postnatal depression, mostly ascertained within 8 weeks postpartum [ 10 , 11 ]. With retrospectively collected data, one systematic review and one meta-analysis reported that women with postnatal depression were more likely to endorse a history of PMDs [ 10 , 11 ], which is in line with our results. The meta-analysis reported an OR of 2.20, 95% CI [1.81,2.68] for PMDs among women with postnatal depression (mostly assessed within 6 months after delivery) [ 10 ]. Correspondingly, our data show that women with PMDs have more than 3 times higher risk of PND within 6 months postpartum.

To our knowledge, no study has examined the association between prenatal depression and PMDs. Our findings on prenatal depression therefore extend knowledge to another subtype of PND that occurs during pregnancy. Although the etiology for prenatal depression is complex [ 40 ], our finding may suggest a subgroup of prenatal depression may be related to hormone changes as well. However, future studies are needed to confirm our results and to understand the biologic link between PMDs and prenatal depression. Interestingly, we found a stronger association between PMDs and PND among multiparous than primiparous women. It is known that primiparous women have a higher risk of PND [ 41 ] while parity is positively associated with PMDs [ 42 ]. It is plausible that premenstrual symptoms can worsen after pregnancy likely due to an escalated abnormal response to hormonal changes in relation to pregnancy [ 15 ]. However, it is unclear whether multiple pregnancies would further deteriorate the pathological response to hormone fluctuations. Future studies are needed to better understand the potential mechanisms.

Our work illustrates a higher risk of PMDs among women who experienced PND. Although many women with PMDs have symptom onset in adolescence [ 43 ], symptom worsening has been reported with increasing age [ 44 ] and parity [ 15 ]. It is possible that women with milder premenstrual symptoms experienced worse symptoms after pregnancy and are therefore first diagnosed with PMD after pregnancy. The delayed diagnosis of PMD could be one reason for this finding [ 45 ]. Interestingly, we noted a stronger association between PMDs and subsequent PND than the association in the other direction. This might be because many PMDs have an early onset [ 43 ], likely before the average age at first childbirth, whereas we targeted the late-onset PMDs in the cohort study. It is also plausible that women with PND are more likely to take antidepressants, which may mitigate premenstrual symptoms. On the other direction, although women with PMDs may use antidepressants as well, women are more likely to discontinue psychotic medications during pregnancy and even after due to breastfeeding [ 46 , 47 ]. However, future studies are warranted to disentangle the role of treatment in the differential associations observed for both directions.

There are several explanations to the bidirectional association between PMDs and PND. First, both PMDs and PND have shared liability with psychiatric disorders [ 35 , 36 ], which may explain the findings. PMDs could also lead to the development of psychiatric comorbidities [ 48 ], which increase the risk of PND. In this scenario, psychiatric disorders are mediators of the studied associations. Indeed, additional adjustment of psychiatric disorders attenuated the associations. However, the bidirectional associations (relative risks) remained robust and even stronger among women without a history of psychiatric disorders, suggesting our findings cannot be entirely explained by psychiatric disorders. On the other hand, although the absolute risk (e.g., probability or incidence rate) of PMDs is higher among women with a psychiatric history, a diagnosis of PND does not translate into an increased risk of PMDs to the same extent as it does for those without a psychiatric history. This is likely because the already heightened risk of PMDs among women with a psychiatric history, particularly among those with a history of depression. However, PMDs or PND have a relatively weaker correlation with other psychiatric disorders compared to depression [ 35 , 36 ]. Among women with a history of other psychiatric disorders, PMDs appeared to confer a higher risk of PND ( Table 3 ) and vice versa ( Table 5 ). Second, PMDs and PND may share other risk factors such as obesity and smoking [ 4 , 49 , 50 ]. However, the bidirectional association persisted after adjustment of BMI and smoking. Childhood adversities could be another shared risk factor [ 51 , 52 ]. However, sibling comparison should to some extent have addressed that, at least with respect to adversities shared between full sisters. Third, PMDs and PND may share genetic susceptibility. The twin heritability was estimated to be around 54% for PND [ 53 ] and 44% to 95% for PMDs [ 54 – 56 ]. Indeed, the attenuation of the associations in sibling comparison lends support to the shared genetic factors and/or familial environmental factors between both disorders. But the associations remained despite the attenuation in sibling comparison. Last, PMDs and PND may share common etiology. The symptom onset of both disorders is linked to hormonal fluctuations, particularly of estrogen and progesterone, which have receptors in the brain, and have been linked to mood alterations [ 57 , 58 ]. PND occurs during a period that is marked with rapid increase of steroid hormones during pregnancy and a rapid decline after delivery [ 7 ]. Similarly, the onset of PMD symptoms typically follows the rapid withdraw of hormones in the late luteal phase [ 8 ]. It is plausible that an abnormal response to natural hormone fluctuations predisposes women to both PMDs and PND. Future research is, however, needed to reveal the potentially shared underlying etiology of both conditions.

The strength of the study lies in the large sample size with long and complete follow-up, the prospectively and independently collected data on PMDs and PND, and covariates that could confound the studied association. The nested-case control study in combination with the transition into a matched cohort study with onward follow-up allowed us to study the association between PMDs and PND in a bidirectional fashion with efficiency, which is equivalent to two independent cohort studies within the same study population. Moreover, the sibling comparisons allowed us to address the influence of familial factors. However, the study has several limitations. First, the clinical diagnosis of PMDs in the Swedish Patient Register has not been validated. Although prospective daily symptom ratings for at least two consecutive menstrual cycles are required for diagnosing PMDs in Sweden according to the guidelines [ 33 ], we cannot confirm that the clinical decision to assign a diagnosis or medical treatment to every single ascertained PMD in the registers is based on prospective daily ratings. However, clinical guidelines are often well followed owing to the state-funded nature of the public healthcare system in Sweden. Moreover, the Swedish Patient Register has fairly high validity in general [ 59 ], with the overall positive predicted value for most diagnoses ranging from 85% to 95% [ 60 ]. For a range of psychiatric disorders [ 61 – 64 ] and gynecologic diseases [ 22 , 65 ], the diagnosis has been reported to have high validity. Lastly, sensitivity analysis restricting to PMDs with at least two specialist-made diagnoses at least 28 days apart yielded similar results. In addition, the diagnostic criteria for PMDs may have changed over time. However, stratification analysis by calendar year showed similar results, suggesting that our results are robust given the changes of labeling and diagnostic criteria for PMDs over time. Second, using prescription of antidepressants to identify PND cases might result in misclassifications because antidepressants are also prescribed for other psychiatric disorders. However, sensitivity analysis restricted to clinically diagnosed PND cases showed comparable results. Moreover, reverse causation may to some extent contribute to the observed associations, although we tried to minimize the risk for such bias through the study design that simulates a prospective approach. For instance, some individuals might already have PMDs before pregnancy but received the diagnosis when seeking healthcare for PND. However, similar results have been found when starting the follow-up 1 year after delivery, when such prevalent PMDs would presumably have been captured sooner after the delivery during the postpartum checkups. Third, we did not have data on the exact date of menstruation return for postpartum women, which could be individually different and affected by multiple factors including breastfeeding practices and mode of delivery. Nevertheless, sensitivity analysis with different starting points of the follow-up yielded similar results. Lastly, relying on the Patient Register, we would have missed cases with less severe symptomology and did not seek healthcare service. Moreover, with the ICD code we used to identify PND, we might have missed a small number of mood disturbances or affective disorders that are not sufficiently severe or long-lasting to be classified as depressive episodes. Our findings thus may not generalize well to women with mild PMDs or PND symptomology.

In conclusion, our findings shed light on the bidirectional association between PMDs and PND, supporting a shared underlying etiology. Preconception and maternity care providers should be aware of the risk of developing PND among women with a history of PMDs. Moreover, healthcare providers may inform women with PND about the potential risk of PMDs when menstruation returns after childbirth. The bidirectional relationship is, to a limited extent, explained by psychiatric comorbidities and familial confounding.

Supporting information

S1 checklist. strobe statement—checklist of items that should be included in reports of observational studies..

https://doi.org/10.1371/journal.pmed.1004363.s001

S1 Methods. Data origin and rational of the choice of covariates.

https://doi.org/10.1371/journal.pmed.1004363.s002

S1 Fig. Flow chart.

https://doi.org/10.1371/journal.pmed.1004363.s003

S1 Table. International Classification of Diseases codes used to define the studied medical conditions.

https://doi.org/10.1371/journal.pmed.1004363.s004

S2 Table. Association of premenstrual disorders (PMDs) with subsequent risk of perinatal depression (PND) adjusted for mediators: A nested case-control study.

https://doi.org/10.1371/journal.pmed.1004363.s005

S3 Table. Stratified association of premenstrual disorders (PMDs) with subsequent perinatal depression (PND): A nested case control study.

https://doi.org/10.1371/journal.pmed.1004363.s006

S4 Table. Stratified association of perinatal depression (PND) with subsequent premenstrual disorders (PMDs): A matched cohort study.

https://doi.org/10.1371/journal.pmed.1004363.s007

S5 Table. Bidirectional link between perinatal depression (PND) with premenstrual disorders (PMDs): Sensitivity analysis.

https://doi.org/10.1371/journal.pmed.1004363.s008

S6 Table. Association of perinatal depression (PND) with subsequent premenstrual disorders (PMDs): A matched cohort study with different start of follow-up.

https://doi.org/10.1371/journal.pmed.1004363.s009

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Tuesday, April 02, 2024 8:35 pm (Paris)

• Mental Health

Postpartum depression: Studies show that fathers suffer too

Psychiatrists have begun to identify the psychological difficulties experienced by men around the birth of their child. According to a French study, 5% of fathers are affected.

By  Julien Lemaignen

Time to 4 min.

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When his wife told him she was pregnant, Vincent was overjoyed. In the months that followed, he bought a cot, went to the chemist as often as necessary and felt like he was well prepared. However, when the birth arrived in October 2021, he didn't feel the "automatic love" he'd expected. The midwife slid the baby into his arms, saying, "This is your daughter; she'll be with you for life." This innocuous yet monumental statement gripped the young father; it was at this moment, he confided, that he began to spiral down "the slide."

This 38-year-old from the French city of Lyon (who wished to remain anonymous) was born very prematurely. As a result, he has suffered from cerebral palsy, severe digestive problems and constant interaction with the medical world. When he had a child, his health problems took on a whole new dimension in his thoughts. "I'd been dealing with death since birth, but, for the first time, I was mortal to someone. I had a huge responsibility and feared that my body would give up on me for good. I said to myself, 'I'm going to die and abandon her; I can't get attached to her.'"

When he came back from the maternity ward, Vincent told his mother all about the birth. "I said that the nurses were amazing, that the hospital was great." Nothing about the baby and nothing about himself: "I was cut off from my emotions." When his wife came home, he couldn't imagine that the baby would stay at home. This 30-something man, "lively and cheerful" in normal circumstances, would just sit prostrate in an armchair. A month and a half later, his wife was at her wits' end. She decided to consult a psychiatrist the couple had met shortly before giving birth. The doctor concluded that he was suffering from postpartum depression.

'I'll never be a good father'

At first, Vincent didn't believe it – he could have sworn that this disorder could only affect mothers. This was hardly surprising, given the lack of interest in this pathology among men in both public debate and in the scientific literature, which contains "far more articles on depression in mothers than in fathers," according to Romain Dugravier, a psychiatrist at the Psychiatry and Neurosciences University Hospital Group of Paris (GHU Paris) and the department head at the Paris Brune Institute Perinatal Psychopathology Center (CPPB).

Yet Vincent's situation is not unique. The French Longitudinal Study since Childhood (ELFE) cohort, which tracks 18,000 children born in France in 2011, has made it possible to estimate the prevalence of such cases. Postpartum depression is thought to affect 5% of fathers, compared with 15% to 16% of mothers, according to a study examining the effects of paternity leave on parents' mental health published in The Lancet Public Health in January 2023 . The Edinburgh Postnatal Depression Scale (EPDS) questionnaire was given to 13,000 mothers and 11,000 fathers two months after birth.

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I thought everyone would be better off without me – I knew it wasn’t post-natal depression but docs dismissed me

• Jennifer Kyte
• Published : 15:00, 30 Mar 2024

A MUM left feeling as though her loved ones would be "better off without her" was mistakenly diagnosed with post-natal depression for years before she discovered her true diagnosis. 

Naomi Farrow, 39, experienced extreme symptoms of depression for five years after the birth of her twins in 2014 - but it took three hospital admissions until one doctor flagged unique signs. 

Until that point, the former NHS worker from Norfolk was told time and time again her symptoms were normal but she always knew something more serious was going on. 

She was diagnosed with bipolar , which in the UK, one in 50 people live with (1.5 million), according to Bipolar UK .

It takes on average nine-and-a-half years for patients to be correctly diagnosed with bipolar, and the average age at diagnosis has increased from 26 to 34 in the last 40 years. 

A person with type bipolar I will normally experience an episode of mania, while a person with bipolar II will experience less severe manic episodes but longer depressive episodes - and doctors may mistake it for depression .

Naomi said: “I’d always felt emotions probably a little stronger than other people.

“I had my first daughter in 2011 and I felt a little down after that but nothing that would warrant going to the GP. 

“Then I got pregnant with twins, the pregnancy was not an easy one, and after the birth, my mental health just went into a serious decline.”

Wake-up call

Naomi struggled to bond with one of her twins, finding herself going into a dark depression and even shutting herself away from the crying babies. 

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“I came back to find my three-year-old trying to stop them crying with a dummy once and that was my wake-up call. I realised something wasn’t right,” she continued.

“I went to the GP and straight away they put me on antidepressants. 

“But with bipolar, antidepressants can send you hyper or even manic depending on what category of bipolar you have.

“I was completely hyper, I imagine it’s like what taking speed feels like. 

“I could see what I had to do in a day and just didn’t stop. I set up a charity for perinatal health, started campaigning, stood as a Lib Dem candidate and all these other bizarre things when my children were still babies.”

I felt like everyone around me would be better off without me, you truly believe that. Naomi

Naomi then split from her husband when the twins were just two years old and the stress of that sent her spiralling.  

“The divorce just tipped me over the edge,” she said. 

“I started having intruding thoughts, suicidal thoughts and feeling like I wasn’t safe. I felt like everyone around me would be better off without me, you truly believe that. 

“I ended up in a psychiatric unit. Between 2017 and 2019 I was in and out of the unit three times, with the longest stay around eight weeks.”

These stays were heartbreaking for Naomi as they took her away from her children.

“They’d be crying down the phone asking me to come home,” she remembered. “It was awful but I was in there for them.” 

Spotting the signs

It wasn’t until the last stay that Naomi finally got the diagnosis she’d been desperate for. 

Up until that point, no one had even mentioned the word bipolar to her. 

But one psychiatrist spotted a link when he asked her about her family history and mental illness. 

On speaking to her mum Naomi discovered that there was evidence of manic depression on her mother’s side of the family, with her grandmother having even been admitted to a psychiatric ward after she’d given birth. 

Bipolar disorder is often linked with family history with genetic factors accounting for approximately 80 per cent of the cause of the condition, according to Healthline.

In November 2019 Naomi was finally diagnosed with bipolar II. She was then taken off her existing medication for depression and instead prescribed Lithium. 

“It instantly brought me down like a lead balloon. I felt like I used to before I had children,” she continued.

“Before I was diagnosed I honestly thought I was mad. Then after the diagnosis I was elated, we knew what was wrong.

"But at the same time, the illness is forever and it’s not something that will ever go away.

“My psychiatrist told me there’s evidence of a link in women who experience a surge of hormones during pregnancy and how that can trigger the bipolar that might have been lying dormant. 

“This is why women are more likely to be diagnosed after they’ve had children.

“Now I look to the future with a bit of worry as I know the menopause also creates a surge of hormones but we’ll cross that bridge when it comes.

“My children are amazing and now recognise when I’m having a low day or a slightly hyper day. 

“They ask jokingly if I’ve remembered to take my meds. I don’t keep it a secret from them, and I hope that helps them as they navigate their own lives.” 

Naomi now juggles her illness with parenting her three children and studying at university for a degree in International Relations. 

During the height of her illness, she also set up a charity www.getmeout.org.uk to help women going through mental health issues after having children. 

But one thing she really wants to change is the time it takes to get people diagnosed with bipolar. 

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“Since Bipolar UK was founded as a charity 40 years ago, we have never stopped campaigning on behalf of those living with bipolar and their families,” CEO of Bipolar UK Simon Kitchen, said.

“To help prevent the high rate of suicide in those with bipolar and to reduce this unacceptable waiting time for a diagnosis, we are currently campaigning for the Government to commit to prioritising bipolar in the implementation of their national suicide prevention strategy and to commit to reducing the average delay to diagnosis from five years to within five years.”

What is bipolar?

Bipolar is usually diagnosed as either bipolar I or bipolar II. This diagnosis is based on the severity of a patient’s manic episodes. 

A person with bipolar I will normally experience an episode of mania, while a person with bipolar II will experience less severe manic episodes but longer depressive episodes.

Manic episodes can include:

• High energy
• Restlessness
• Trouble concentrating
• Feelings of extreme happiness
• Behaviours that can lead to harmful consequences
• Lack of sleep

Major depressive episodes linked to Bipolar II usually last two weeks, and many doctors misdiagnose it as depression. 

Depressive episodes can include:

• Feeling sad, hopeless or irritable most of the time
• Lacking energy
• Difficulty concentrating and remembering things
• Loss of interest in everyday activities
• Feelings of emptiness, worthlessness, despair, guilt and pessimism
• Being delusional, having hallucinations and disturbed or illogical thinking
• Lack of appetite
• Difficulty sleeping
• Waking up early
• Suicidal thoughts

If you are worried about bipolar or want to learn more Bipolar UK has a 20-minute free e-learning course as well as a mood disorder questionnaire .  

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