Antenatal maternal mental health as determinant of postpartum depression in a population based mother–child cohort (Rhea Study) in Crete, Greece

  • Katerina Koutra
  • Maria Vassilaki
  • Vaggelis Georgiou
  • Antonios Koutis
  • Panos Bitsios
  • Leda Chatzi
  • Manolis Kogevinas
Original Paper



Antenatal maternal mental health has been identified as an important determinant of postpartum depression (PPD). We investigated the occurrence of depression both antenatally and postnatally and examined whether maternal trait anxiety and depression during pregnancy were associated with PPD at 8 weeks postpartum in a prospective mother–child cohort (Rhea Study) in Crete, Greece.


438 women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Trait subscale of the State-Trait Anxiety Inventory (STAI-Trait) questionnaires assessing antenatal depression and anxiety, respectively, during the third trimester of pregnancy as well as the EPDS at 8 weeks postpartum.


The prevalence of women with probable depression (EPDS score ≥13) was 16.7 % at 28–32 weeks of pregnancy and 13.0 % at 8 weeks postpartum. A per 5 unit increase in the STAI-Trait subscale increased the odds for PPD by 70 % (OR = 1.70, 95 % CI 1.41, 2.05), whereas a per unit increase in EPDS during pregnancy increased the odds for PPD by 27 % (OR = 1.27, 95 % CI 1.19, 1.36).


Our findings suggest that antenatal maternal psychological well-being has a significant effect on PPD, which might have important implications for early detection during pregnancy of women at risk for postpartum depression.


Antenatal anxiety Antenatal depression Postpartum depression 


  1. 1.
    Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR (2004) Prevalence of depression during pregnancy: systematic review. Obstet Gynecol 103(4):698–709PubMedCrossRefGoogle Scholar
  2. 2.
    Evans J, Heron J, Francomb H, Oke S, Golding J (2001) Cohort study of depressed mood during pregnancy and after childbirth. BMJ 323(7307):257–260PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T (2005) Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 106(5 Pt 1):1071–1083PubMedCrossRefGoogle Scholar
  4. 4.
    Halbreich U, Karkun S (2006) Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 91(2–3):97–111PubMedCrossRefGoogle Scholar
  5. 5.
    Josefsson A, Berg G, Nordin C, Sydsjo G (2001) Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 80(3):251–255PubMedCrossRefGoogle Scholar
  6. 6.
    O’Hara M, Swain A (1996) Rates and risk of postpartum depression: a meta-analysis. Intl Rev Psychiatr 8(1):37–54CrossRefGoogle Scholar
  7. 7.
    Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150:782–786PubMedCrossRefGoogle Scholar
  8. 8.
    Gonidakis F, Rabavilas AD, Varsou E, Kreatsas G, Christodoulou GN (2008) A 6-month study of postpartum depression and related factors in Athens, Greece. Compr Psychiatry 49(3):275–282PubMedCrossRefGoogle Scholar
  9. 9.
    Leonardou AA, Zervas YM, Papageorgiou CC, Marks MN, Tsartsara EC, Antsaklis A, Christodoulou GN, Soldatos CR (2009) Validation of the Edinburgh Postnatal Depression Scale and prevalence of postnatal depression at 2 months postpartum in a sample of Greek mothers. J Reprod Infant Psyc 27(1):28–39CrossRefGoogle Scholar
  10. 10.
    Cox JL, Murray D, Chapman G (1993) A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 163:27–31PubMedCrossRefGoogle Scholar
  11. 11.
    Nonacs R, Cohen LS (2002) Depression during pregnancy: diagnosis and treatment options. J Clin Psychiatry 63(Suppl 7):24–30PubMedGoogle Scholar
  12. 12.
    O’Hara MW (1997) The nature of postpartum depressive disorders. In: Murray L, Cooper P (eds) Postpartum depression and child development. Guilford, New York, pp 3–31Google Scholar
  13. 13.
    Llewellyn AM, Stowe ZN, Nemeroff CB (1997) Depression during pregnancy and the puerperium. J Clin Psychiatry 58(Suppl. 2):26–32PubMedGoogle Scholar
  14. 14.
    Beck CT (1996) A meta-analysis of predictors of postpartum depression. Nurs Res 45(5):297–303PubMedCrossRefGoogle Scholar
  15. 15.
    Beck CT (2001) Predictors of postpartum depression: an update. Nurs Res 50(5):275–285PubMedCrossRefGoogle Scholar
  16. 16.
    Heron J, O’Connor TG, Evans J, Golding J, Glover V (2004) The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord 80(1):65–73PubMedCrossRefGoogle Scholar
  17. 17.
    Larsson C, Sydsjo G, Josefsson A (2004) Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms. Obstet Gynecol 104(3):459–466PubMedCrossRefGoogle Scholar
  18. 18.
    Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ, Joffe H, Gilman MW (2006) Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Commun H 60:221–227CrossRefGoogle Scholar
  19. 19.
    Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY (2007) Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 110(5):1102–1112PubMedCrossRefGoogle Scholar
  20. 20.
    Austin M-P, Tully L, Parker G (2007) Examining the relationship between antenatal anxiety and postnatal depression. J Affect Disord 101(1–3):169–174PubMedCrossRefGoogle Scholar
  21. 21.
    Robertson E, Grace S, Wallington T, Steward DE (2004) Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiat 26(4):289–295CrossRefGoogle Scholar
  22. 22.
    Oates MR, Cox JL, Neema S, Asten P, Glangeaud-Freudenthal N, Figueiredo B, Gorman LL, Hacking S, Hirst E, Kammerer MH, Klier CM, Seneviratne G, Smith M, Sutter-Dallay A-L, Valoriani V, Wickberg B, Yoshida K, Group atT-P (2004) Postnatal depression across countries and cultures: a qualitative study. Br J Psychiatry 184(Suppl. 46):S10–S16CrossRefGoogle Scholar
  23. 23.
    Thorpe KJ, Dragonas T, Golding J (1992) The effects of psychosocial factors on the emotional well-being of women during pregnancy: a cross-cultural study of Britain and Greece. J Reprod Infant Psyc 10(4):191–204CrossRefGoogle Scholar
  24. 24.
    Hoffman S, Hatch MC (2000) Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women. Health Psychol 19(6):535–543PubMedCrossRefGoogle Scholar
  25. 25.
    Field T, Diego M, Hernandez-Reif M, Figueiredo B, Deeds O, Ascencio A, Schanberg S, Kuhn C (2010) Comorbid depression and anxiety effects on pregnancy and neonatal outcome. Infant Behav Dev 33(1):23–29PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Chatzi L, Plana E, Daraki V, Karakosta P, Alegkakis D, Tsatsanis C, Kafatos A, Koutis A, Kogevinas M (2009) Metabolic syndrome in early pregnancy and risk of preterm birth. Am J Epidemiol 170(7):829–836PubMedCrossRefGoogle Scholar
  27. 27.
    Westerway SC, Davison A, Cowell S (2000) Ultrasonic fetal measurements: new Australian standards for the new millennium. Aust N Z J Obstet Gynaecol 40(3):297–302PubMedCrossRefGoogle Scholar
  28. 28.
    Spielberger C, Gorsuch R, Lushene R, Vagg P, Jacobs G (1970) Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press, Palo AltoGoogle Scholar
  29. 29.
    Liakos A, Giannitsi S (1984) Reliability and validity of the modified Greek version of the Spielberger State-Trait Anxiety Inventory. Encephalos 21:71–76Google Scholar
  30. 30.
    Murray L, Carothers AD (1990) The validation of the EPDS on a community sample. Br J Psychiatry 157:288–290PubMedCrossRefGoogle Scholar
  31. 31.
    Matthey S, Henshaw C, Elliot S, Barnett B (2006) Variability in use of cut off scores and formats on the Edinburgh Postnatal Depression Scale—implications for clinical and research practice. Arch Womens Ment Health 9(6):309–315PubMedCrossRefGoogle Scholar
  32. 32.
    Vivilaki VG, Dafermos V, Kogevinas M, Bitsios P, Lionis C (2009) The Edinburgh Postnatal Depression Scale: translation and validation for a Greek sample. BMC Public Health 9:329PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Wood SN (2006) Generalized additive models: an introduction with R. Chapman and Hall/CRC Press, Boca RatonGoogle Scholar
  34. 34.
    Rubertsson C, Waldenstrom U, Wickberg B (2003) Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample. J Reprod Infant Psyc 21(2):113–123CrossRefGoogle Scholar
  35. 35.
    Bunevicius R, Kusminskas L, Bunevicius A, Nadisauskiene RJ, Jureniene K, Pop VJ (2009) Psychosocial risk factors for depression during pregnancy. Acta Obstet Gynaecol Scand 88:599–605CrossRefGoogle Scholar
  36. 36.
    Bowen A, Muhajarine N (2006) Antenatal depression. Can Nurse 102(9):26–30PubMedGoogle Scholar
  37. 37.
    Da Costa D, Rippen N, Dritsa M, Ring A (2003) Self-supported leisure-time physical activity during pregnancy and relationship to psychological well-being. J Psychosom Obst Gyn 24(2):111–119CrossRefGoogle Scholar
  38. 38.
    Haas JS, Jackson RA, Fuentes-Afflick E, Stewart AL, Dean ML, Brawarsky P, Escobar GJ (2004) Changes in the health status of women during and after pregnancy. J Gen Intern Med 20(1):45–51CrossRefGoogle Scholar
  39. 39.
    Goodwin A, Astbury J, McMeeken J (2000) Body image and psychological well-being in pregnancy. A comparison of exercisers and non-exercisers. Aust N Z J Obstet Gynaecol 40(4):442–447PubMedCrossRefGoogle Scholar
  40. 40.
    Poudevigne MS, O’Connor PJ (2005) Physical activity and mood during pregnancy. Med Sci Sports Exerc 37(8):1374–1380PubMedCrossRefGoogle Scholar
  41. 41.
    de Tychey C, Briancon S, Lighezzolo J, Spitz E, Kabuth B, de Luigi V, Messembourg C, Girvan F, Rosati A, Thockler A, Vincent S (2008) Quality of life, postnatal depression and baby gender. J Clin Nurs 17(3):312–322PubMedGoogle Scholar
  42. 42.
    Xie RH, Liao S, Xie H, Guo Y, Walker M, Wen SW (2011) Infant sex, family support and postpartum depression in a Chinese cohort. J Epidemiol Commun Health 65(8):722–726CrossRefGoogle Scholar
  43. 43.
    Ekuklu G, Tokuc B, Eskiocak M, Berberoglu U, Saltik A (2004) Prevalence of postpartum depression in Edirne, Turkey, and related factors. J Reprod Med 49(11):908–914PubMedGoogle Scholar
  44. 44.
    Patel V, Rodrigues M, DeSouza N (2002) Gender, poverty, and postnatal depression: a study of mothers in Goa, India. Am J Psychiatry 159(1):43–47PubMedCrossRefGoogle Scholar
  45. 45.
    Edwards DRL, Porter SAM, Stein GS (1994) A pilot study of postnatal depression following caesarean section using two retrospective self-rating instruments. J Psychosom Res 38(2):111–117PubMedCrossRefGoogle Scholar
  46. 46.
    Hannah P, Adams D, Lee A, Glover V (1992) Links between early postpartum mood and postnatal depression. Br J Psychiatry 160:777–780PubMedCrossRefGoogle Scholar
  47. 47.
    Lobel M, DeLuca RS (2007) Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications. Soc Sci Med 64:2272–2284PubMedCrossRefGoogle Scholar
  48. 48.
    Carter FA, Frampton CM, Mulder RT (2006) Cesarean section and postpartum depression: a review of the evidence examining the link. Psychosom Med 68(2):321–330PubMedCrossRefGoogle Scholar
  49. 49.
    Green JM, Murray D (1994) The use of the Edinburgh Postnatal Depression Scale in research to explore the relationships between antenatal and postnatal dysphoria. In: Cox J, Holden J (eds) Perinatal psychiatry: use and misuse of the Edinburgh Postnatal Depression Scale. Gaskell, London, pp 180–198Google Scholar
  50. 50.
    Johanson R, Chapman G, Murray D, Johnson I, Cox J (2000) The North Staffordshire maternity hospital prospective study of pregnancy-associated depression. J Psychosom Obstet Gynaecol 21(2):93–97PubMedCrossRefGoogle Scholar
  51. 51.
    Marcus S, Flynn H, Blow F, Barry K (2003) Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health 12(4):373–380CrossRefGoogle Scholar
  52. 52.
    Harris B, Huckle P, Thomas R, Johns S, Fung H (1989) The use of rating scales to identify post-natal depression. Br J Psychiatry 154:813–817PubMedCrossRefGoogle Scholar
  53. 53.
    Thompson WM, Harris B, Lazarus J, Richards C (1998) A comparison of the performance of rating scales used in the diagnosis of postnatal depression. Acta Psychiatry Scand 98(3):224–227CrossRefGoogle Scholar
  54. 54.
    Seguin L, Potvin L, St Denis M, Loiselle J (1999) Depressive symptoms in the late postpartum among low socioeconomic status women. Birth 26:157–163PubMedCrossRefGoogle Scholar
  55. 55.
    Koutra K, Chatzi L, Bagkeris M, Vassilaki M, Bitsios P, Kogevinas M (2012) Antenatal and postnatal maternal mental health as determinants of infant neurodevelopment at 18 months of age in a mother-child cohort (Rhea Study) in Crete, Greece. Soc Psychiatry Psychiatr Epidemiol 48(8):1335–1345PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Katerina Koutra
    • 1
    • 2
  • Maria Vassilaki
    • 1
  • Vaggelis Georgiou
    • 1
  • Antonios Koutis
    • 1
  • Panos Bitsios
    • 2
  • Leda Chatzi
    • 1
  • Manolis Kogevinas
    • 3
    • 4
    • 5
    • 6
  1. 1.Department of Social Medicine, Faculty of MedicineUniversity of CreteHeraklionGreece
  2. 2.Department of Psychiatry and Behavioral Sciences, Faculty of MedicineUniversity of CreteHeraklionGreece
  3. 3.National School of Public HealthAthensGreece
  4. 4.Centre for Research in Environmental Epidemiology (CREAL)BarcelonaSpain
  5. 5.Municipal Institute of Medical ResearchBarcelonaSpain
  6. 6.CIBER Epidemiologia y Salud Pública (CIBERESP)MadridSpain

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