Trajectories of maternal symptoms of anxiety and depression. A 13-year longitudinal study of a population-based sample

Psychological resources and flexibility predict resilient mental health trajectories during the French covid-19 lockdown

The implementation of lockdowns and the Covid-19 pandemic situation have negatively impacted mental health (anxiety, depression). However, little is known about individual differences in the longitudinal reactions to lockdown. We designed a longitudinal study (a) to identify the various trajectories of symptoms of depression and anxiety in the general population during and after lockdown; (b) to determine which positive psychological resources prevent individuals from falling into groups with the most severe trajectories; (c) to test the mediating role of psychological flexibility. We collected and analysed longitudinal data on a sample of French participants (N = 1399, M_age = 43.4; SD_age = 12; 87.8% women) during the end of the first lockdown. Participants were asked to report their psychological resources and (in)flexibility at baseline and symptoms of anxiety and depression at each measurment occasion (five weekly observations from 17 March to 11 May 2020, including baseline). Using growth mixture modelling, seven dynamic profiles of symptoms were identified: four for depression and three for anxiety. Resilience emerged as the most frequent trajectory. Wisdom, optimism, hope, self-efficacy and peaceful disengagement significantly prevented individuals from belonging to the symptomatic groups. Moreover, psychological flexibility emerged as a significant mediator of these effects. This study highlights the importance of cultivating protective factors and psychological flexibility to prevent mental health damage during potentially traumatic events (PTE) and to favour resilience trajectories.

Anxiety Symptoms Among Patients With Systemic Lupus Erythematosus Persist Over Time and Are Independent of SLE Disease Activity

OBJECTIVE

The objectives of this study are to identify patterns of anxiety symptomology over time among patients with systemic lupus erythematosus (SLE) and to assess the longitudinal relationship between SLE disease activity and anxiety symptomology.

METHODS

Longitudinal data from 139 patients with American College of Rheumatology or Systemic Lupus International Collborating Clinic (SLICC)-classified SLE were analyzed. Anxiety symptomology was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Emotional Distress: Anxiety Short Form 8a. SLE disease activity was measured using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)-2000 (S2K) and S2K Responder Index 50 (S2K RI-50). Group-based trajectory modeling (GBTM) identified longitudinal trajectories of anxiety symptomology. The relationship between disease activity and anxiety over time was assessed using multilevel linear regressions.

RESULTS

The mean patient age was 40.2 years (standard deviation [SD], 12.7); 90.6% were female, and 56.1% were of Black race. All patients had at least three PROMIS anxiety scores over an average of 30.9 months (SD, 13.0). GBTM identified four trajectories of anxiety symptomology, labeled as the following: low (LA), average (AA), moderate (MA), and high anxiety (HA). Black patients were 2.47 (95% confidence interval: 1.19-5.12) times as likely as White patients to be classified into the MA or HA groups compared with the LA or AA groups. On multivariable analysis, active SLE disease was not significantly associated with anxiety over time (P = 0.19).

CONCLUSION

Anxiety trajectories remained stable over time, and racial differences in anxiety severity were observed. SLE disease activity was not longitudinally associated with anxiety after controlling for depression and other factors. Further understanding of the factors that contribute to the persistence of anxiety among individuals with SLE is necessary.

The relationship between motherhood and use of mental health care services among married migrant and non-migrant women: a national register study

BACKGROUND

Giving birth to one's first child is a life changing event. Beyond the post-partum period, little is known about the association between becoming a mother and mental disorder among migrant women. This study investigates outpatient mental health (OPMH) service use, a proxy for mental disorder, among married migrant and non-migrant women who become mothers and those who do not.

METHODS

Using Norwegian register data, we followed 90,195 married women, aged 18-40 years, with no children at baseline between 2008-2013 to see if becoming a mother was associated with OPMH service use. Data were analysed using discrete time analyses.

RESULTS

We found an interaction between motherhood and migrant category. Married non-migrant mothers, both in the perinatal period and beyond, had lower odds of OPMH use than married non-mothers. There was no association between motherhood and OPMH service use for migrants. However, there was no significant interaction between motherhood and migrant category when we excluded women who had been in Norway less than five years. Among women aged 25-40 years, a stable labour market attachment was associated with lower odds of OPMH use for non-migrants but not migrants, regardless of motherhood status.

CONCLUSIONS

The perinatal period is not associated with increased odds of OPMH use and appears to be associated with lower odds for married non-migrant women. Selection effects and barriers to care may explain the lack of difference in OPMH service use that we found across motherhood status and labour market attachment for married migrant women. Married migrant women in general have a lower level of OPMH use than married non-migrants. Married migrant women with less than five years in Norway and those with no/weak labour market attachment may experience the greatest barriers to care. Further research to bridge the gap between need for, and use of, mental health care among migrant women is required.

Comorbid Anxiety and Depression and Related Factors Among Pregnant and Postpartum Chinese Women During the Coronavirus Disease 2019 Pandemic

Objective: To identify the prevalence of comorbid anxiety and depression (CAD) and analyze the relationship between CAD and sociodemographic and obstetric-related variables in pregnant and postpartum Chinese women during the COVID-19 pandemic. Methods: Participants were 2,237 pregnant and postpartum women (aged 19-47 years) who visited various medical institutions in China between February 28, 2020, and April 26, 2020. They were asked to complete an online survey assessing the anxiety and depression, obstetric characteristics, and sociodemographic variables. The women were grouped into the following categories in accordance with the Generalized Anxiety Disorder Scale-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9): (a) CAD, (b) "anxiety only," (c) "depression only," and (d) "no depression or anxiety." After estimating the prevalence of CAD, "anxiety only," and "depression only," we carried out chi-squared tests and multiple logistic regression analysis to examine the related factors between these groups of pregnant and postpartum Chinese women. Results: Comorbid anxiety and depression, "anxiety only," and "depression only," occurred in 6.3, 5.8, and 3.9% of participants, respectively. The prevalence rates of CAD during the first, second, and third trimesters of pregnancy and the postpartum period were found to be 7.4, 6.5, 5.7, and 8.2%, respectively. The factors that differed among the groups were age (p < 0.05), marital status (p < 0.001), level of education (p < 0.05), family support (p < 0.001), and total live births (p < 0.001). "Poor family support" (odds ratio (OR): 1.90; 95% confidence interval (CI): 1.30-2.78; p = 0.0009) and "no birth" (OR: 1.91; 95% CI: 1.32-2.75; p = 0.0006) remained significant factors for the CAD group, while "poor family support" (OR: 2.16; 95% CI: 1.34-3.47; p = 0.0015) remained a significant factor for the "depression only" group when their results were compared to those of the "no depression or anxiety" group in the multiple logistic regression analysis. Conclusion: Pregnant and postpartum Chinese women with poor family support and primipara are at high risk for CAD during the COVID-19 pandemic. These results support the need for targeted perinatal programs to address CAD in pregnant and postpartum women during the pandemic period.

Understanding trajectories of externalizing problems: Stability and emergence of risk factors from infancy to middle adolescence

Despite considerable efforts to understand the processes that underlie the development of externalizing behavior problems, it is still unclear why externalizing problems remain chronically high for some children, emerge early and cease by late childhood for others, and arise in adolescence in some cases. The purpose of this study was to examine how a wide range of child and family risk factors are linked to trajectories of externalizing behavior and how these relationships vary from infancy to middle adolescence. We used data from the community-based Norwegian Tracking Opportunities and Problems (TOPP) study sample (n = 921). A Cholesky factorization model was specified to separate stable and emerging risk doses across four developmental periods (infancy, early and middle childhood, and middle adolescence). Children in the High Stable class were characterized by substantially elevated risk levels in multiple domains throughout the study period. Children in the High Childhood Limited class had very high levels of temperamental emotionality, internalizing symptoms, and maternal mental distress, suggesting a substantial intrinsic emotional basis for their externalizing problems. Intrinsic factors seemed less salient for the Adolescent Onset class. These findings emphasize the need for a dynamic perspective on risk factors and support the importance of prevention and intervention efforts across multiple domains from early childhood and throughout adolescence.

National Norms and Correlates of the PHQ-8 and GAD-7 in Parents of School-age Children

Anxiety and depressive disorders are global public health concerns, and research suggests that these disorders are common in parents and can adversely influence family functioning. However, little is known about normative levels of anxiety and depressive symptoms in parents of school-age children. The present study reports on generalized anxiety and depressive symptoms in 1570 parents and guardians of a nationally representative sample of children ages five to twelve years using two widely used and validated questionnaires: the eight-item variant of the Patient Health Questionnaire depression scale (PHQ-8) and the seven-item Generalized Anxiety Disorder scale (GAD-7). Moderate to severe levels of generalized anxiety symptoms were reported in 12.7% of the total sample and moderate to severe levels of depressive symptoms were reported in 14.1% of the sample; 17.7% of the sample reported moderate to severe levels of either generalized anxiety or depressive symptoms. This percentage was higher for females, younger parents and guardians, and parents and guardians reporting lower household incomes. These data, collected online in early 2018, may be useful for researchers and clinicians studying and treating anxiety and depression in parents. Further, these data provide a baseline for researchers currently studying the impact of changes related to the novel coronavirus (COVID-19) pandemic (e.g., school closures) on the mental health of parents of school-age children.

The Long-Term Impact of Maternal Anxiety and Depression Postpartum and in Early Childhood on Child and Paternal Mental Health at 11-12 Years Follow-Up

BACKGROUND

Postpartum maternal anxiety and depression can affect child development and family functioning. However, the long-term impact of postpartum maternal anxiety and depression on child and paternal mental health is understudied. The present large-scale prospective cohort study is one of the first to investigate whether maternal anxiety and depressive symptoms postpartum and at child age 5-6 years separately and synergistically increase paternal anxiety and depressive symptoms and child emotional problems in early adolescence at age 11-12 years. Secondly, we investigated whether concurrent paternal anxiety and depressive symptoms at child age 11-12 years moderated the association between maternal anxiety and depressive symptoms in the postpartum period and at child age 5-6 years with child emotional problems at age 11-12 years.

METHODS

This study is part of the Amsterdam Born Children and Development (ABCD) cohort study, the Netherlands (N = 2.298). Maternal postpartum anxiety and depressive symptoms were assessed using the State-Trait Anxiety Inventory (STAI) and the Center for Epidemiologic Studies Depression Scale (CES-D) at 13 weeks postpartum. Maternal anxiety and depressive symptoms at child age 5-6 years and parental anxiety and depressive symptoms at 11-12 years were assessed using the Depression Anxiety Stress Scale (DASS-21). Child emotional problems were reported by the child and a teacher using the Strengths and Difficulties Questionnaire (SDQ). Multivariable linear regression was conducted, adjusted for demographic, perinatal/obstetric confounders, and affective symptoms of the other family members at 11-12 years.

RESULTS

Neither maternal anxiety nor depressive symptoms were related to paternal depressive symptoms at child age 11-12 years, while maternal postpartum depressive symptoms, depressive symptoms at 5-6 years and maternal anxiety at 5-6 years were positively related to paternal anxiety at 11-12 years. However, effect sizes were small. Only maternal postpartum depression was positively but weakly associated with more child emotional problems at 11-12 years. Although paternal concurrent affective symptoms were positively related to more child emotional problems in early adolescence, they did not moderate the association between maternal symptoms and child emotional problems.

CONCLUSIONS

Our results indicate that fathers and children seem to be affected only to a small extent by maternal postpartum anxiety or depression.

Performance of the 3-item screener, the Edinburgh Postnatal Depression Scale, the Hopkins Symptoms Checklist-15 and the Self-Reporting Questionnaire and Pregnancy Risk Questionnaire, in screening of depression in antenatal clinics in the Blantyre district of Malawi

Background

Screening instruments for antenatal depression vary in performance. This study aimed at assessing the performance of a range of screening instruments in detecting depressive symptoms in antenatal clinics in Blantyre district, Malawi.

Methods

A cross-sectional study was conducted to screen for depression among women attending 8 selected antenatal clinics in Blantyre district using 3-item screener, Edinburgh Postnatal Depression Scale (EPDS), Hopkins Symptoms Checklist-15 (HSCL-15), Self-Reporting Questionnaire (SRQ) and Pregnancy Risk Questionnaire (PRQ). The instruments were administered to a random sample of 480 pregnant women. Data were analysed using SPSS 22.0 testing for performance differences in proportions of screen positives and how screen positive results might differ by particular variables.

Results

The prevalence estimates yielded by screening instruments ranged from 12.9% (SRQ) to 42.1% (3-item screener). There were no significant differences in prevalence estimates for EPDS, HSCL-15, PRQ and SRQ. There were performance differences in the proportions of screen positives with significant systematic differences between proportions of screen positives of PRQ and SRQ (p<.001), EPDS and HSCL-15 (p=.001), HSCL and PRQ (p<.001), and EPDS and SRQ (p<.001). Screen positive results on HSCL-15, PRQ, 3-item screener and EPDS were found to differ by variables such as “not being supported by partner” which resulted in respondents having ≥3 times chances to screen positive on these four instruments. The screen positive results on SRQ were found not to differ by age, education, employment status, marital status, setting, gestation and number of pregnancies.

Conclusions

There were minimal variations in the performance of the EPDS, SRQ and HSCL-15 as standard public health screening instruments. However, systematic differences between proportions of screen positives exist and screen positive results from these instruments differed by demographics. It is important to validate screening instruments against a gold standard to ensure relevant clinical outcomes for pregnant women with depression.

Failure to Respond after Reinstatement of Antidepressant Medication: A Systematic Review

BACKGROUND

Following remission of an anxiety disorder or a depressive disorder, antidepressants are frequently discontinued and in the case of symptom occurrence reinstated. Reinstatement of antidepressants seems less effective in some patients, but an overview is lacking. This systematic review aimed to provide insight into the magnitude and risk factors of response failure after reinstatement of antidepressants in patients with anxiety disorders, depressive disorders, obsessive-compulsive disorder (OCD), or posttraumatic stress disorder (PTSD).

METHOD

PubMed, Embase, and trial registers were systematically searched for studies in which patients: (1) had an anxiety disorder, a depressive disorder, OCD, or PTSD and (2) experienced failure to respond after reinstatement of a previously effective antidepressant.

RESULTS

Ten studies reported failure to respond following antidepressant reinstatement. The phenomenon was observed in 16.5% of patients with a depressive disorder, OCD, and social phobia and occurred in all common classes of antidepressants. The range of response failure was broad, varying between 3.8 and 42.9% across studies. No risk factors for failure to respond were investigated. The overall study quality was limited.

CONCLUSION

Research investigating response failure is scarce and the study quality limited. Response failure occurred in a substantial minority of patients. Contributors to the relevance of this phenomenon are the prevalence of the investigated disorders, the number of patients being treated with antidepressants, and the occurrence of response failure for all common classes of antidepressants. This systematic review highlights the need for studies systematically investigating this phenomenon and associated risk factors.

Failure to Respond after Reinstatement of Antidepressant Medication: A Systematic Review

BACKGROUND

Following remission of an anxiety disorder or a depressive disorder, antidepressants are frequently discontinued and in the case of symptom occurrence reinstated. Reinstatement of antidepressants seems less effective in some patients, but an overview is lacking. This systematic review aimed to provide insight into the magnitude and risk factors of response failure after reinstatement of antidepressants in patients with anxiety disorders, depressive disorders, obsessive-compulsive disorder (OCD), or posttraumatic stress disorder (PTSD).

METHOD

PubMed, Embase, and trial registers were systematically searched for studies in which patients: (1) had an anxiety disorder, a depressive disorder, OCD, or PTSD and (2) experienced failure to respond after reinstatement of a previously effective antidepressant.

RESULTS

Ten studies reported failure to respond following antidepressant reinstatement. The phenomenon was observed in 16.5% of patients with a depressive disorder, OCD, and social phobia and occurred in all common classes of antidepressants. The range of response failure was broad, varying between 3.8 and 42.9% across studies. No risk factors for failure to respond were investigated. The overall study quality was limited.

CONCLUSION

Research investigating response failure is scarce and the study quality limited. Response failure occurred in a substantial minority of patients. Contributors to the relevance of this phenomenon are the prevalence of the investigated disorders, the number of patients being treated with antidepressants, and the occurrence of response failure for all common classes of antidepressants. This systematic review highlights the need for studies systematically investigating this phenomenon and associated risk factors.

Prevalence trends of pre- and postnatal depression in Japanese women: A population-based longitudinal study

BACKGROUND

This study aimed to describe the prevalence trends of pre- and postnatal depression, via measures of the Edinburgh Postnatal Depression Scale (EPDS) total and factor scores, from 20 weeks' gestation to 3 months postpartum, stratified by parity, in a Japanese female population.

METHODS

A longitudinal, population-based study was conducted among perinatal women giving birth at maternity facilities in Setagaya area of Tokyo, Japan. Of the 1775 women who participated, 1311 women met the inclusion criteria of this analysis. All data, including EPDS, were collected via self-administrated questionnaires at 20 weeks' gestation and at 5 time points postpartum, from the first few days to 3 months postpartum. We divided EPDS items into three factors: "anxiety," "anhedonia," and "depression," according to factor analysis.

RESULTS

The prevalence of individuals exhibiting depressive symptoms, EPDS total score, and each factor score peaked at two weeks postpartum in primiparas (EPDS total = 5.58, anhedonia = 0.47, anxiety = 2.64, and depression = 1.23). In contrast, the EPDS total score and factor scores for "anxiety" and "depression" gradually decreased for multiparas, from the prenatal to postpartum period (EPDS total 3.33, 3.03, 3.03, 2.72, 2.76, and 2.37).

LIMITATIONS

Each factor score was not weighted; instead, we simply added up the item scores ranging from 0 to 3 for each question. Additionally, the population representativeness of Japanese women was not high, although the sample was population-based and had a high follow-up rate.

CONCLUSIONS

This study shows that the trends of EPDS total and factor scores differ by parity throughout the pre- and postnatal periods among a Japanese female population.

Maternal Psychological Distress and Offspring Psychological Adjustment in Emerging Adulthood: Findings from Over 18 Years

OBJECTIVE

To examine the long-term prediction of psychological maladaptive (i.e., symptoms of anxiety and depression) and adaptive adjustment (i.e., self-efficacy) in emerging adult offspring from trajectories of maternal psychological distress from toddlerhood to adolescence.

METHOD

Trajectories of maternal psychological distress (low, moderate, high, and low-rising patterns) from toddlerhood (age 1.5 years) to adolescence (age 14.5 years) were used to predict psychological adjustment in emerging adult offspring (age 18-20 years) (n = 400).

RESULTS

Adverse maternal distress trajectories during childhood were linked to maladaptive and adaptive adjustment in adult offspring. Consistently high maternal distress levels experienced across childhood predicted higher symptoms of anxiety and depression and lower self-efficacy than low maternal distress trajectories. Two other adverse maternal distress trajectories (consistently moderate and low-rising patterns) compared with the low trajectory predicted higher offspring depressive symptoms. The findings persisted when adjusting for potential confounders: offspring gender and maternal education, relationship status, language, and economy.

CONCLUSION

The current study showed longitudinal multi-informant impact from adverse maternal distress trajectories to adult offspring maladjustment over 18 years, emphasizing the importance of early identification and prevention.

Social adversity in pregnancy and trajectories of women's depressive symptoms: A longitudinal study

BACKGROUND

Sound evidence has linked the experience of adversity with depression. Less is known about this association over time.

AIM

The aim of this study is to determine whether or not social adversity experienced by pregnant women is associated with their patterns of depressive symptoms over their reproductive life course.

METHODS

Data were obtained from a cohort of women collected at their first obstetrical clinic visit of an index pregnancy (time-point 1) and at a further six time-points to 27 years following the birth. Latent Class Growth Modelling was used to estimate trajectories of women's depressive symptoms over this time period. Logistic regression modelling determined the prospective association between measures of adversity in pregnancy and 27-year postpartum depression trajectories, controlling for potential confounders.

FINDINGS

Experiencing financial problems, housing problems, serious disagreements with partners and with others, and experiencing serious health problems in pregnancy were associated with membership of high and middle depression trajectories over the 27 years. Having someone close die or have a serious illness was associated with the high depression trajectory only. Younger maternal age and low family-income at first clinic visit were also associated with an increased risk of women's membership of both high and middle depression trajectories.

CONCLUSIONS

Experiencing adversity during pregnancy predicts subsequent patterns of maternal depression over an extended period of women's reproductive life course. It is not clear whether women's experiences of adversity during pregnancy were causally associated with subsequent depression or whether there are other explanations of the observed association.

Adverse trajectories of mental health problems predict subsequent burnout and work-family conflict - a longitudinal study of employed women with children followed over 18 years

BACKGROUND

The long-term consequence of experiencing mental health problems may lead to several adverse outcomes. The current study aims to validate previous identified trajectories of mental health problems from 1993 to 2006 in women by examining their implications on subsequent work and family-related outcomes in 2011.

METHODS

Employed women (n = 439) with children were drawn from the Tracking Opportunities and Problems-Study (TOPP), a community-based longitudinal study following Norwegian families across 18 years. Previous identified latent profiles of mental health trajectories (i.e., High; Moderate; Low-rising and Low levels of mental health problems over time) measured at six time points between 1993 and 2006 were examined as predictors of burnout (e.g., exhaustion and disengagement from work) and work-family conflict in 2011 in univariate and multivariate analyses of variance adjusted for potential confounders (age, job demands, and negative emotionality).

RESULTS

We found that having consistently High and Moderate symptoms as well as Low-Rising symptoms from 1993 to 2006 predicted higher levels of exhaustion, disengagement from work and work-family conflict in 2011. Findings remained unchanged when adjusting for several potential confounders, but when adjusting for current mental health problems only levels of exhaustion were predicted by the mental health trajectories.

CONCLUSIONS

The study expands upon previous studies on the field by using a longer time span and by focusing on employed women with children who experience different patterns of mental health trajectories. The long-term effect of these trajectories highlight and validate the importance of early identification and prevention in women experiencing adverse patterns of mental health problems with regards to subsequent work and family-related outcomes.

Explaining risk for suicidal ideation in adolescent offspring of mothers with depression

BACKGROUND

It is well-established that offspring of depressed mothers are at increased risk for suicidal ideation. However, pathways involved in the transmission of risk for suicidal ideation from depressed mothers to offspring are poorly understood. The aim of this study was to examine the contribution of potential mediators of this association, including maternal suicide attempt, offspring psychiatric disorder and the parent-child relationship.

METHOD

Data were utilized from a population-based birth cohort (ALSPAC). Three distinct classes of maternal depression symptoms across the first 11 years of the child's life had already been identified (minimal, moderate, chronic-severe). Offspring suicidal ideation was assessed at age 16 years. Data were analysed using structural equation modelling.

RESULTS

There was evidence for increased risk of suicidal ideation in offspring of mothers with chronic-severe depression symptoms compared to offspring of mothers with minimal symptoms (odds ratio 3.04, 95% confidence interval 2.19-4.21). The majority of this association was explained through maternal suicide attempt and offspring psychiatric disorder. There was also evidence for an independent indirect effect via the parent-child relationship in middle childhood. There was no longer evidence of a direct effect of maternal depression on offspring suicidal ideation after accounting for all three mediators. The pattern of results was similar when examining mechanisms for maternal moderate depression symptoms.

CONCLUSIONS

Findings highlight that suicide prevention efforts in offspring of depressed mothers should be particularly targeted at both offspring with a psychiatric disorder and offspring whose mothers have made a suicide attempt. Interventions aimed at improving the parent-child relationship may also be beneficial.

Longitudinal symptom course in adults with recurrent depression: Impact on impairment and risk of psychopathology in offspring

BACKGROUND

Major depressive disorder (MDD) is common and is associated with an increased risk of psychopathology in offspring. However, depression shows considerable heterogeneity in its course over time. The aim of this study is to examine the relationship between parent depression symptom trajectories and (i) quality of life and social impairment and (ii) psychiatric disorder and depression symptoms in their offspring.

METHOD

Participants were from a longitudinal study of 337 parents with recurrent MDD and their adolescent offspring. Families were assessed on three occasions over four years. Parent depressive symptoms and current MDD diagnosis were assessed using the Schedules for Clinical Assessment in Neuropsychiatry. Adult quality of life and social impairment were derived from the EuroQol and current employment status. Psychiatric outcomes in offspring were assessed using the Child and Adolescent Psychiatric Assessment.

RESULTS

Using latent class growth analysis, three distinct classes of parental depression symptoms were identified (asymptomatic, mild, and chronic high). Parent depression classes were associated with their own quality of life and social impairment, and with psychiatric disorder and depression symptoms in their offspring.

LIMITATIONS

(i) We were unable to test associations with specific offspring disorders, (ii) we did not address the direction of effects underlying associations, and (iii) the sample consisted primarily of mothers and findings may not generalise to depressed fathers.

CONCLUSION

Longitudinal assessments of depressive symptoms in parents could help to identify families who are most in need of early intervention.

Association between Maternal Depression Symptoms across the First Eleven Years of Their Child's Life and Subsequent Offspring Suicidal Ideation

Depression is common, especially in women of child-bearing age; prevalence estimates for this group range from 8% to 12%, and there is robust evidence that maternal depression is associated with mental health problems in offspring. Suicidal behaviour is a growing concern amongst young people and those exposed to maternal depression are likely to be especially at high risk. The aim of this study was to utilise a large, prospective population cohort to examine the relationship between depression symptom trajectories in mothers over the first eleven years of their child’s life and subsequent adolescent suicidal ideation. An additional aim was to test if associations were explained by maternal suicide attempt and offspring depressive disorder. Data were utilised from a population-based birth cohort: the Avon Longitudinal Study of Parents and Children. Maternal depression symptoms were assessed repeatedly from pregnancy to child age 11 years. Offspring suicidal ideation was assessed at age 16 years. Using multiple imputation, data for 10,559 families were analysed. Using latent class growth analysis, five distinct classes of maternal depression symptoms were identified (minimal, mild, increasing, sub-threshold, chronic-severe). The prevalence of past-year suicidal ideation at age 16 years was 15% (95% CI: 14-17%). Compared to offspring of mothers with minimal symptoms, the greatest risk of suicidal ideation was found for offspring of mothers with chronic-severe symptoms [OR 3.04 (95% CI 2.19, 4.21)], with evidence for smaller increases in risk of suicidal ideation in offspring of mothers with sub-threshold, increasing and mild symptoms. These associations were not fully accounted for by maternal suicide attempt or offspring depression diagnosis. Twenty-six percent of non-depressed offspring of mothers with chronic-severe depression symptoms reported suicidal ideation. Risk for suicidal ideation should be considered in young people whose mothers have a history of sustained high levels of depression symptoms, even when the offspring themselves do not have a depression diagnosis.

Predictors of persistent maternal depression trajectories in early childhood: results from the EDEN mother-child cohort study in France

BACKGROUND

Maternal depression in the pre- and postpartum period may set women on a course of chronic depressive symptoms. Little is known about predictors of persistently elevated depressive symptoms in mothers from pregnancy onwards. The aims of this study are to determine maternal depression trajectories from pregnancy to the child's fifth birthday and identify associated risk factors.

METHOD

Mothers (N = 1807) from the EDEN mother-child birth cohort study based in France (2003-2011) were followed from 24-28 weeks of pregnancy to their child's fifth birthday. Maternal depression trajectories were determined with a semi-parametric group-based modelling strategy. Sociodemographic, psychosocial and psychiatric predictors were explored for their association with trajectory class membership.

RESULTS

Five trajectories of maternal symptoms of depression from pregnancy onwards were identified: no symptoms (60.2%); persistent intermediate-level depressive symptoms (25.2%); persistent high depressive symptoms (5.0%); high symptoms in pregnancy only (4.7%); high symptoms in the child's preschool period only (4.9%). Socio-demographic predictors associated with persistent depression were non-French origin; psychosocial predictors were childhood adversities, life events during pregnancy and work overinvestment; psychiatric predictors were previous mental health problems, psychological help, and high anxiety during pregnancy.

CONCLUSIONS

Persistent depression in mothers of young children is associated to several risk factors present prior to or during pregnancy, notably anxiety. These characteristics precede depression trajectories and offer a possible entry point to enhance mother's mental health and reduce its burden on children.

Identifying depressive symptom trajectory groups among Korean adults and psychosocial factors as group determinants

BACKGROUND

Longitudinal research is needed to examine the depressive symptom trajectories of different groups during adulthood and their antecedents and consequences, because depressive symptoms may be changeable and heterogeneous over time.

AIMS

This study examined the number of trajectory groups describing the depressive symptoms of Korean adults, as well as the shape of the trajectories and the association between trajectory group membership and psychosocial factors identified based on the ecosystem model.

METHOD

This study used Nagin's semi-parametric group-based modeling to analyze Year 1 to Year 7 data from Korea Welfare Panel Survey (N = 13,735), a nationally representative sample of community-dwelling adults.

RESULTS

Three distinct trajectory groups were identified: a low stable depressive symptoms group, a moderate depressive symptoms group and a high depressive symptoms group. Result from multinominal logit analysis showed that all psychosocial factors except family relationships affected the likelihood of membership in the three depressive symptoms groups. Especially, self-esteem was the psychosocial factor with the largest impact on depressive symptom trajectory group membership. When screening for depressive symptoms, individuals with a low socioeconomic status should be a primary concern and intervention should be made available to them.

CONCLUSION

Prevention or intervention with members of the identified trajectory groups would likely require integrative approaches targeting psychosocial factors across multiple contexts.

Socioeconomic inequalities in health trajectories in Switzerland: are trajectories diverging as people age?

Do socioeconomic differences in health status increase as people age, reflecting cumulative advantage or disadvantage in health trajectories? Life course research hypothesises that cumulative advantage/disadvantage (CAD) is an important underlying social process that shape inequalities as people age. The objective of this study is to examine whether health trajectories are diverging as people age across socioeconomic positions (education, employment status and income). In a random sample of 3,665 respondents living in Switzerland (Swiss Household Panel 2004-2011), trajectories of self-rated health, body mass index, depression and medicated functioning were examined with multilevel regression models. The results showed that employment status and income were associated with diverging health trajectories among men; however, only a few associations supported the CAD hypothesis. Education was rarely associated with diverging health trajectories. In conclusion, little evidence was found to support the CAD model.

Pathways to suicide-related behavior in offspring of mothers with depression: the role of offspring psychopathology

OBJECTIVE

Offspring of mothers with depression are a high-risk group for the development of suicide-related behavior. These offspring are therefore a priority for preventive interventions; however, pathways contributing to risk, including specific aspects of offspring psychopathology, remain unclear. The aim of this study was to examine whether offspring symptoms of major depressive disorder (MDD), generalized anxiety disorder (GAD), disruptive behavior disorder (DBD), attention-deficit/hyperactivity disorder (ADHD), and alcohol abuse independently mediate the association between maternal depression and offspring suicide-related behavior.

METHOD

Data were used from a population-based birth cohort, the Avon Longitudinal Study of Parents and Children (ALSPAC). Three distinct classes of depression symptoms across the mothers' first 11 years of their child's life were identified (minimal, moderate, chronic-severe). Offspring psychopathology was assessed at age 15 years and suicide-related behavior at age 16 years. Data were analyzed using structural equation modeling.

RESULTS

There was evidence for increased risk of suicidal ideation in offspring of mothers with chronic-severe depression symptoms in comparison to offspring of mothers with minimal symptoms (odds ratio = 3.04, 95% CI = 2.19, 4.21). This association was independently mediated by offspring MDD, GAD, and DBD symptoms. The same mechanisms were found for offspring of mothers with moderate depression symptoms over time. Results were similar for offspring suicide attempt except for additional evidence of an indirect effect through offspring ADHD symptoms.

CONCLUSION

Findings highlight that suicide prevention efforts in offspring of mothers with depression should not only be targeted at offspring with MDD; it is also important to consider offspring with other forms of psychopathology.

Long-term trajectories of maternal depressive symptoms and their antenatal predictors

BACKGROUND

Depressive symptoms, often long-term or recurrent, are common among mothers of young children and a well-known risk for child well-being. We aimed to explore the antecedents of the long-term trajectories of maternal depressive symptoms and to define the antenatal factors predicting the high-symptom trajectories.

METHODS

The sample comprised 329 mothers from maternity centers. Maternal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale (EPDS) antenatally and at two months, six months, 4-5 years, 8-9 years and 16-17 years after delivery. Maternal expectations concerning the baby were assessed with the Neonatal Perception Inventory (NPI). Background information was gathered with questionnaires.

RESULTS

A model including four symptom trajectories (very low, low-stable, high-stable and intermittent) was selected to describe the symptom patterns over time. The high-stable and the intermittent trajectory were both predicted pairwise by a high antenatal EPDS sum score as well as high EPDS anxiety and depression subscores but the other predictors were specific for each trajectory. In multivariate analyses, the high-stable trajectory was predicted by a high antenatal EPDS sum score, a high EPDS anxiety subscore, diminished life satisfaction, loneliness and more negative expectations of babies on average. The intermittent trajectory was predicted by a high antenatal EPDS sum score, a poor relationship with own mother and urgent desire to conceive.

LIMITATIONS

Only self-report questionnaires were used. The sample size was rather small.

CONCLUSIONS

The results suggest a heterogeneous course and background of maternal depressive symptoms. This should be considered in intervention planning.

Mental health trajectories and their embeddedness in work and family circumstances: a latent state-trait approach to life-course trajectories

Mental health trajectories are known to be influenced by work and family circumstances. However, few studies have examined both of these influences simultaneously in a longitudinal manner. The life-course perspective stresses the importance of examining trajectories in terms of both stable and dynamic components. In this article we use structural equation models (latent state-trait, LST) to distinguish the stable and situational components of mental health trajectories and hypothesise that situational mental health is influenced by satisfaction with work and family, and this effect differs by gender. An analysis of data from a nationally representative sample of 1616 working Swiss residents (2000-2006) shows that mental health trajectories are mostly stable and only slightly sensitive to situational influences. However, situational influences in a given wave do predict situational influences in the next wave. Satisfaction with work and family influences situational mental health in both genders, but the impact is greater for men. In conclusion, the LST approach allows for the examination of mental health trajectories from a life-course perspective by distinguishing stable and situational components. Mental health trajectories are more stable and constant than they are dependent on work and family circumstances, and men are more sensitive to family circumstances than women.

Depression and anxiety trajectories among women who undergo an elective cesarean section

BACKGROUND

Depression and anxiety are important mood changes in childbearing women. However, changes in depression and anxiety over time in women who undergo an elective cesarean section (CS) have not yet been elucidated. We aimed to characterize the trajectories of depressive and anxiety symptoms, and patterns of co-occurrence, and examined the associated predictors of depression and anxiety courses.

METHODS

A prospective longitudinal study of childbearing women (N = 139) who underwent a CS was conducted. Depressive and anxiety symptoms were respectively assessed using the Edinburgh Postnatal Depression Scale and State Anxiety Inventory, in the third trimester and at 1 day, 1 week, and 1 and 6 months postpartum.

RESULTS

Group-based modeling identified three distinct trajectories of depressive symptoms: group 1 (low, 30.9%), group 2 (mild, 41.7%), and group 3 (high, 27.3%). Four group trajectories of anxiety symptoms were identified: group 1 (low, 19.4%), group 2 (mild, 44.6%), group 3 (high, 28.8%), and group 4 (very high, 7.2%). Mild symptoms of both depression and anxiety were the most common joint trajectory. Depression trajectories were significantly related to anxiety trajectories (p<0.001). Predictors of the joint trajectory included the pre-pregnant body mass index (odds ratio (OR): 2.42, 95% confidence interval (CI): 1.1 ∼ 6.3) and a poor sleep score (OR: 3.2, 95% CI: 1.4 ∼ 7.3) in the third trimester.

CONCLUSIONS

Distinctive trajectories and co-occurrence patterns of depressive and anxiety symptoms were identified. Our findings suggest a need for greater attention to continuous assessment of psychological well-being among women who undergo an elective CS.

A trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care

BACKGROUND

Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care.

METHODS

789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months.

RESULTS

Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables.

LIMITATIONS

Adult only cohort, self-report measures.

CONCLUSIONS

Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.

Pathways from maternal distress and child problem behavior to adolescent depressive symptoms: a prospective examination from early childhood to adolescence

OBJECTIVE

The main aim of this study was to identify the pathways from maternal distress and child problem behaviors (i.e., internalizing and externalizing problems) across childhood and their impact on depressive symptoms during adolescence among girls and boys.

METHOD

Data from families of 921 Norwegian children in a 15-year longitudinal community sample were used. Using structural equation modeling, the authors explored the interplay between maternal-reported distress and child problem behaviors measured at 5 time points from early (ages 1.5, 2.5, and 4.5 years) and middle (age 8.5 years) childhood to early adolescence (age 12.5 years), and their prediction of self-reported depressive symptoms during adolescence (ages 14.5 and 16.5 years).

RESULTS

The findings revealed paths from internalizing and externalizing problems throughout the development for corresponding problems (homotypic paths) and paths from early externalizing to subsequent internalizing problems (heterotypic paths). The findings suggest 2 pathways linking maternal-rated risk factors to self-reported adolescent depressive symptoms. There was a direct path from early externalizing problems to depressive symptoms. There was an indirect path from early maternal distress going through child problem behavior to depressive symptoms. In general, girls and boys were similar, but some gender-specific effects appeared. Problem behaviors in middle childhood had heterotypic paths to subsequent problems only for girls.

CONCLUSION

The findings highlight the developmental importance of child externalizing problems, as well as the impact of maternal distress as early as age 1.5 years for the development of adolescent depressive symptoms. Findings also indicate a certain vulnerable period in middle childhood for girls. NOTE: See Supplemental Digital Content 1, at http://links.lww.com/JDBP/A45, for a video introduction to this article.

Trajectories of maternal symptoms of depression and anxiety over 13 years: the influence of stress, social support, and maternal temperament

Background

Depression and anxiety are the most common mental health problems among women, with various negative impacts both for the women concerned and their families. Greater understanding of developmental trajectories of maternal symptoms of depression and anxiety over the child rearing period would have significant benefits for public health, informing prevention and treatment approaches. The aim of the current study was to examine whether stressors related to child rearing and living conditions, social support, and maternal temperament, predicted mothers’ membership in groups with different trajectories of symptoms of depression and anxiety during 13 years of the child rearing phase.

Methods

The data were from a prospective, longitudinal study of 913 mothers in Norway followed from when their children were 18 months old (time 1) until they were 14.5 years (time 6) (the TOPP study). Multinomial logistic regression analyses were used to test whether child related stressors, stressors related to the living conditions, social support and maternal temperament at time 1 predicted membership in groups based on maternal symptoms of depression and anxiety over the subsequent 13 years.

Results

Temperamental distress, followed by child related stressors, were the strongest predictors of membership in a group with high symptoms of depression and anxiety over time. Stressors related to living conditions, and social support from partner and friends/family were also significant predictors. No interaction effects among predictors were found.

Conclusions

This study indicates that factors present early in the child rearing phase may provide substantial prediction of the variance in maternal symptoms of depression and anxiety over the following 13 years. Temperamental distress and child related stressors were the strongest predictors of membership in different depression and anxiety symptom trajectory groups.

Parenting stress and emotional wellbeing in mothers and fathers of preschool children

AIMS

The aims of the study were to compare parenting stress and emotional wellbeing in mothers and fathers of preschool children, to look for predictors of different aspects of parenting stress in mothers and fathers, and to discriminate parenting stress from psychological distress and anxiety.

METHODS

We studied 256 mothers and 204 fathers of children aged 1-7 years. The Swedish Parenthood Stress Questionnaire (SPSQ) assesses stress related to parenting. Emotional wellbeing was defined by the General Health Questionnaire-28 (GHQ-28) and the State Anxiety Inventory (STAI-X1) that measures psychological distress and anxiety, respectively.

RESULTS

Fathers reported significantly more social isolation than mothers (P < 0.001). On all other parameters mothers, had higher scores, representing more stress and less wellbeing than fathers. Anxiety and psychological stress were strong predictors of parental stress in both mothers and fathers. Furthermore, maternal parental stress was predicted by birth of subsequent children and younger child age. Higher educational attainment predicted increased role restriction in fathers and more health problems in mothers. A principal component analysis (PCA) of the SPSQ, GHQ-28, and STAI-X1 showed that all endpoints of the analysis are positively correlated.

CONCLUSIONS

Fathers reported significantly more social isolation, but less role restriction, incompetence and state anxiety than mothers. The SPSQ together with GHQ-28 and STAI-X1 allow a targeted screening aimed at contrasting parents who experience reduced emotional wellbeing with those who struggle with stress directly related to their parenting role.

Course trajectories of unipolar depressive disorders identified by latent class growth analysis

BACKGROUND

Current classification of unipolar depression reflects the idea that prognosis is essential. However, do DSM categories of major depressive disorder (MDD), dysthymic disorder (Dysth) and double depression (DD=MDD+Dysth) indeed adequately represent clinically relevant course trajectories of unipolar depression? Our aim was to test DSM categories (MDD, Dysth and DD) in comparison with empirically derived prognostic categories, using a prospectively followed cohort of depressed patients.

METHOD

A large sample (n=804) of out-patients with unipolar depression were derived from a prospective cohort study, the Netherlands Study of Depression and Anxiety (NESDA). Using latent class growth analysis (LCGA), empirically derived 2-year course trajectories were constructed. These were compared with DSM diagnoses and a wider set of putative predictors for class membership.

RESULTS

Five course trajectories were identified, ranging from mild severity and rapid remission to high severity and chronic course trajectory. Contrary to expectations, more than 50% of Dysth and DD were allocated to classes with favorable course trajectories, suggesting that current DSM categories do not adequately represent course trajectories. The class with the most favorable course trajectory differed on several characteristics from other classes (younger age, more females, less childhood adversity, less somatic illnesses, lower neuroticism, higher extraversion). Older age, earlier age of onset and lower extraversion predicted poorest course trajectory.

CONCLUSIONS

MDD, Dysth and DD did not adequately match empirically derived course trajectories for unipolar depression. For the future classification of unipolar depression, it may be wise to retain the larger, heterogeneous category of unipolar depression, adopting cross-cutting dimensions of severity and duration to further characterize patients.

Advancing nursing science through health trajectory research: an introduction

The Minnesota Center for Health Trajectory Research has focused on developing ways to better understand how interventions influence health trajectories during transitional, acute, or chronic health challenges across the life span. The health trajectory perspective advances nursing science by providing a person-centered point of view that emphasizes change in health over time within individuals, families, groups, or communities. Theoretical considerations and statistical modeling approaches used in studying health trajectories, along with exemplars from nursing research studies from this special issue of Nursing Research, are highlighted.