Social Psychiatry and Psychiatric Epidemiology

, Volume 54, Issue 10, pp 1219–1230 | Cite as

Association between perinatal depressive symptoms and suicidal risk among low-income South African women: a longitudinal study

  • Emily C. GarmanEmail author
  • Annibale Cois
  • Marguerite Schneider
  • Crick Lund
Original Paper



The aim of this study was to assess the association between depressive symptoms and suicidal risk over time among perinatal women at risk for depression antenatally, and assess modifying effects of age, perinatal stage and depressive symptom trajectory.


A total of 384 adult pregnant women were recruited from two antenatal clinics in an informal settlement near Cape Town, South Africa, and followed up at eight months gestation, and at 3- and 12-month postpartum. The MINI 6.0 Suicidality module and the Hamilton Depression Rating Scale (HDRS) were used to measure suicidal risk and depression, respectively. Generalised Estimating Equations were used to assess the association between change in depressive symptoms from one assessment to the next (predictor) and change in suicide score or change in suicidal risk (score ≥ 9) (outcomes).


HDRS scores were positively correlated with suicide score (95% CI 0.35, 0.78; p < 0.001), and with odds of being at moderate risk for suicide, after controlling for risk of suicide at the previous assessment (adjusted odds ratio = 1.15; 95% CI 1.09, 1.22; p < 0.001). Age was a significant effect modifier: change in HDRS scores was not associated with change in suicide scores among participants aged 35–45 years. Secondary analyses indicated that a decrease in HDRS score was associated with a decrease in suicide scores, but an increase in HDRS score was not associated with change in suicide score.


Depression and suicide are overlapping but relatively independent phenomena, especially among older or more chronically depressed perinatal women.


Suicide Depression Perinatal Longitudinal South Africa 



The original RCT was supported by the National Institute of Mental Health of the National Institutes of Health [U19MH095699]. This study is an output of the PRogramme for Improving Mental health carE (PRIME), supported by the UK Department for International Development [201446]. The funders did not have any role in the study design, data collection, analysis or interpretation of the data, or in the writing of the report. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the UK Governments’ official policies.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

All participants recruited in the randomized-controlled trial and included in the present study provided informed written consent. The original randomized-controlled trial received ethical approval from the University of Cape Town (UCT)’s Human Research Ethics Committee (HREC REF 226/2011), and so did this present study (HREC REF 835/2015).


  1. 1.
    World Health Organization (2018) Global Health Estimates 2016: Deaths by cause, age, sex, by country and by region, 2000–2016. World Health Organization, GenevaGoogle Scholar
  2. 2.
    Bachmann S (2018) Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health 15(7):1425–1447CrossRefGoogle Scholar
  3. 3.
    Petroni S, Patel V, Patton G (2015) Why is suicide the leading killer of older adolescent girls? Lancet 386(10008):2031–2032CrossRefGoogle Scholar
  4. 4.
    National Committee for Confidential Enquiries into Maternal Deaths (2018) Saving Mothers 2014–2016: Seventh triennial report on confidential enquiries into maternal deaths in South Africa: Short report. CCEMD, Ministry of Health, PretoriaGoogle Scholar
  5. 5.
    Lindahl V, Pearson JL, Colpe L (2005) Prevalence of suicidality during pregnancy and the postpartum. Arch Women Mental Health 8(2):77–87CrossRefGoogle Scholar
  6. 6.
    Rochat TJ, Bland RM, Tomlinson M, Stein A (2013) Suicide ideation, depression and HIV among pregnant women in rural South Africa. Health (N Y) 5(3A):650–661Google Scholar
  7. 7.
    Onah MN, Field S, Bantjes J, Honikman S (2017) Perinatal suicidal ideation and behaviour: psychiatry and adversity. Arch Women's Mental Health 20(2):321–331CrossRefGoogle Scholar
  8. 8.
    Ronsmans C, Lewis G, Hurt L, Physick N, Macfarlane A, Abrahams C (2000) Mortality in pregnant and non-pregnant women in England & Wales 1997–2002: are pregnant women healthier. Why Mothers Die 2002:272–278Google Scholar
  9. 9.
    Rochat TJ, Richter LM, Doll HA, Buthelezi NP, Tomkins A, Stein A (2006) Depression among pregnant rural South African women undergoing HIV testing. JAMA 295(12):1373–1378CrossRefGoogle Scholar
  10. 10.
    Tomlinson M, O’Connor MJ, le Roux IM, Stewart J, Mbewu N, Harwood J, Rotheram-Borus MJ (2013) Multiple risk factors during pregnancy in South Africa: the need for a horizontal approach to perinatal care. Prev Sci 15(3):277–282CrossRefGoogle Scholar
  11. 11.
    Schwartz SR, Rees H, Mehta S, Venter WDF, Taha TE, Black V (2012) High incidence of unplanned pregnancy after antiretroviral therapy initiation: findings from a prospective cohort study in South Africa. PLoS ONE 7(4):e36039CrossRefGoogle Scholar
  12. 12.
    Jewkes RK, Dunkle K, Nduna M, Shai N (2010) Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet 376(9734):41–48CrossRefGoogle Scholar
  13. 13.
    Bantjes J, Iemmi V, Coast E, Channer K, Leone T, McDaid D, Palfreyman A, Stephens B, Lund C (2016) Poverty and suicide research in low-and middle-income countries: systematic mapping of literature published in English and a proposed research agenda. Global Mental Health 3:e32CrossRefGoogle Scholar
  14. 14.
    Mars B, Burrows S, Hjelmeland H, Gunnell D (2014) Suicidal behaviour across the African continent: a review of the literature. BMC Public Health 14(1):606CrossRefGoogle Scholar
  15. 15.
    Dewing S, Tomlinson M, le Roux IM, Chopra M, Tsai AC (2013) Food insecurity and its association with co-occurring postnatal depression, hazardous drinking, and suicidality among women in peri-urban South Africa. J Affect Disord 150(2):460–465CrossRefGoogle Scholar
  16. 16.
    Woody C, Ferrari A, Siskind D, Whiteford H, Harris M (2017) A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord 219:86–92CrossRefGoogle Scholar
  17. 17.
    Rochat TJ (2011) Depression among pregnant women testing for HIV in rural South Africa. Stellenbosch University, StellenboschGoogle Scholar
  18. 18.
    Cooper PJ, Tomlinson M, Swartz L, Woolgar M, Murray L, Molteno C (1999) Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. Br J Psychiatry 175(6):554–558CrossRefGoogle Scholar
  19. 19.
    Arsenault-Lapierre G, Kim C, Turecki G (2004) Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry 4(1):37–47CrossRefGoogle Scholar
  20. 20.
    Holma KM, Haukka J, Suominen K, Valtonen HM, Mantere O, Melartin TK, Sokero TP, Oquendo MA, Isometsä ET (2014) Differences in incidence of suicide attempts between bipolar I and II disorders and major depressive disorder. Bipolar Disord 16(6):652–661CrossRefGoogle Scholar
  21. 21.
    Khasakhala L, Sorsdahl K, Harder V, Williams D, Stein D, Ndetei D (2011) Lifetime mental disorders and suicidal behaviour in South Africa. Afr J Psychiatry 14(2):134–139CrossRefGoogle Scholar
  22. 22.
    Nock MK, Hwang I, Sampson N, Kessler RC, Angermeyer M, Beautrais A, Borges G, Bromet E, Bruffaerts R, De Girolamo G (2009) Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS Med 6(8):856CrossRefGoogle Scholar
  23. 23.
    Baron E, Bass J, Murray SM, Schneider M, Lund C (2017) A systematic review of growth curve mixture modelling literature investigating trajectories of perinatal depressive symptoms and associated risk factors. J Affect Disord 223:194–208CrossRefGoogle Scholar
  24. 24.
    Santos H, Tan X, Salomon R (2017) Heterogeneity in perinatal depression: how far have we come? A systematic review. Arch Women's Mental Health 20(1):1–13CrossRefGoogle Scholar
  25. 25.
    Garman E, Schneider M, Lund C (2019) Perinatal depressive symptoms among low-income South African women: trajectories and predictors. BMC Pregnancy Childbirth (under review) Google Scholar
  26. 26.
    Garman E, Cois A, Tomlinson M, Rotheram-Borus MJ, Lund C (2019) Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36 months old. Soc Psychiatry Psychiatr Epidemiol (accepted)Google Scholar
  27. 27.
    Kasckow J, Youk A, Anderson SJ, Dew MA, Butters MA, Marron MM, Begley AE, Szanto K, Dombrovski AY, Mulsant BH (2016) Trajectories of suicidal ideation in depressed older adults undergoing antidepressant treatment. J Psychiatr Res 73:96–101CrossRefGoogle Scholar
  28. 28.
    Prinstein MJ, Nock MK, Simon V, Aikins JW, Cheah CS, Spirito A (2008) Longitudinal trajectories and predictors of adolescent suicidal ideation and attempts following inpatient hospitalization. J Consult Clin Psychol 76(1):92–103CrossRefGoogle Scholar
  29. 29.
    Goldston DB, Erkanli A, Daniel SS, Heilbron N, Weller BE, Doyle O (2016) Developmental trajectories of suicidal thoughts and behaviors from adolescence through adulthood. J Am Acad Child Adolesc Psychiatry 55(5):400–407CrossRefGoogle Scholar
  30. 30.
    Madsen T, Van Spijker B, Karstoft K-I, Nordentoft M, Kerkhof AJ (2016) Trajectories of suicidal ideation in people seeking web-based help for suicidality: secondary analysis of a Dutch randomized controlled trial. J Med Internet Res 18(6):e178CrossRefGoogle Scholar
  31. 31.
    Miller AB, Eisenlohr-Moul T, Giletta M, Hastings PD, Rudolph KD, Nock MK, Prinstein MJ (2017) A within-person approach to risk for suicidal ideation and suicidal behavior: examining the roles of depression, stress, and abuse exposure. J Consult Clin Psychol 85(7):712–722CrossRefGoogle Scholar
  32. 32.
    Sokero P, Eerola M, Rytsälä H, Melartin T, Leskelä U, Lestelä-Mielonen P, Isometsä E (2006) Decline in suicidal ideation among patients with MDD is preceded by decline in depression and hopelessness. J Affect Disord 95(1–3):95–102CrossRefGoogle Scholar
  33. 33.
    Kerr DC, Reinke WM, Eddy JM (2013) Trajectories of depressive symptoms and externalizing behaviors across adolescence: associations with histories of suicide attempt and ideation in early adulthood. Suicide Life Threat Behav 43(1):50–66CrossRefGoogle Scholar
  34. 34.
    Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC (1998) The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59(Suppl 20):22–33PubMedGoogle Scholar
  35. 35.
    Lund C, Schneider M, Davies T, Nyatsanza M, Honikman S, Bhana A, Bass J, Bolton P, Dewey M, Joska J, Kagee A, Myer L, Petersen I, Prince M, Stein DJ, Thornicroft G, Tomlinson M, Alem A, Susser E (2014) Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial. Trials 15:457. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150(6):782–786CrossRefGoogle Scholar
  37. 37.
    De Bruin GP, Swartz L, Tomlinson M, Cooper PJ, Molteno C (2004) The factor structure of the Edinburgh Postnatal Depression scale in a South African peri-urban settlement. South Afr J Psychol 34(1):113–121CrossRefGoogle Scholar
  38. 38.
    Lawrie T, Hofmeyr G, De Jager M, Berk M (1998) Validation of the Edinburgh postnatal depression scale on a cohort of South African women. S Afr Med J 88(10):1340–1344PubMedGoogle Scholar
  39. 39.
    Sheehan D, Lecrubier Y (2010) MINI International Neuropsychiatric Interview English Version 6.0.0 (online)Google Scholar
  40. 40.
    Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23(1):56–62CrossRefGoogle Scholar
  41. 41.
    Davies T, Baron EC, Lund C, Schneider M (2019) Adaptation and validation of a structured version of the Hamilton Depression Rating Scale for use by non-clinicians in South Africa (AFFIRM-HDRS). International Journal of Mental Health Systems (under review)Google Scholar
  42. 42.
    StataCorp (2015) Stata Statistical Software: Release, vol 14. StataCorp LP, College Station, TXGoogle Scholar
  43. 43.
    Dang Q, Mazumdar S, Houck PR (2008) Sample size and power calculations based on generalized linear mixed models with correlated binary outcomes. Comput Methods Programs Biomed 91(2):122–127CrossRefGoogle Scholar
  44. 44.
    Bobo WV, Angleró GC, Jenkins G, Hall-Flavin DK, Weinshilboum R, Biernacka JM (2016) Validation of the 17-item Hamilton Depression Rating Scale definition of response for adults with major depressive disorder using equipercentile linking to Clinical Global Impression scale ratings: analysis of Pharmacogenomic Research Network Antidepressant Medication Pharmacogenomic Study (PGRN-AMPS) data. Human Psychopharmacol Clin Exp 31(3):185–192CrossRefGoogle Scholar
  45. 45.
    Fuhr DC, Calvert C, Ronsmans C, Chandra PS, Sikander S, De Silva MJ, Patel V (2014) Contribution of suicide and injuries to pregnancy-related mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Psychiatry 1(3):213–225CrossRefGoogle Scholar
  46. 46.
    Szanto K, Mulsant BH, Houck P, Dew MA, Reynolds CF (2003) Occurrence and course of suicidality during short-term treatment of late-life depression. Arch Gen Psychiatry 60(6):610–617CrossRefGoogle Scholar
  47. 47.
    Joe S, Stein DJ, Seedat S, Herman A, Williams DR (2008) Non-fatal suicidal behavior among South Africans. Soc Psychiatry Psychiatr Epidemiol 43(6):454–461CrossRefGoogle Scholar
  48. 48.
    Putnam K, Wilcox M, Robertson-Blackmore E, Sharkey K, Bergink V, Munk-Olsen T, Deligiannidis KM, Payne J, Altemus M, Newport J (2017) Clinical phenotypes of perinatal depression and time of symptom onset: analysis of data from an international consortium. Lancet Psychiatry 4(6):477–485CrossRefGoogle Scholar
  49. 49.
    Howard LM, Flach C, Mehay A, Sharp D, Tylee A (2011) The prevalence of suicidal ideation identified by the Edinburgh Postnatal Depression Scale in postpartum women in primary care: findings from the RESPOND trial. BMC Pregnancy Childbirth 11(1):57CrossRefGoogle Scholar
  50. 50.
    Department of Health (2015) Guidelines for maternity care in South Africa: A manual for clinics, community health centres and district hospitals, 4th edn. Department of Health, PretoriaGoogle Scholar
  51. 51.
    Honikman S, van Heyningen T, Field S, Baron EC, Tomlinson M (2012) Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLoS Med 9(5):e1001222CrossRefGoogle Scholar
  52. 52.
    Davies T, Schneider M, Nyatsanza M, Lund C (2016) “The sun has set even though it is morning”: Experiences and explanations of perinatal depression in an urban township, Cape Town. Transcult Psychiatry 53(3):286–312CrossRefGoogle Scholar
  53. 53.
    Turecki G, Brent DA (2016) Suicide and suicidal behaviour. Lancet 387(10024):1227–1239CrossRefGoogle Scholar
  54. 54.
    Iemmi V, Bantjes J, Coast E, Channer K, Leone T, McDaid D, Palfreyman A, Stephens B, Lund C (2016) Suicide and poverty in low-income and middle-income countries: a systematic review. Lancet Psychiatry 3(8):774–783CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Emily C. Garman
    • 1
    Email author
  • Annibale Cois
    • 2
    • 3
  • Marguerite Schneider
    • 1
  • Crick Lund
    • 1
    • 4
  1. 1.Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
  2. 2.Division of Epidemiology and Biostatistics, School of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
  3. 3.Burden of Disease Research UnitSouth African Medical Research CouncilTygerbergSouth Africa
  4. 4.Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK

Personalised recommendations