Resea ch A icle
The Connec ions o P egnancy-, Deli e y-, and In an -Rela ed
Risk Fac o s and Nega i e Li e E en s on Pos pa um Dep ession
and Thei Role in Fi s and Recu en Dep ession
Pi jo Ke unen,1Ee a Kois inen,2and Jukka Hin ikka3,4
1Depa men o Gene al Hospi al Psychia y, No h Ka elia Cen al Hospi al, 80210 Joensuu, Finland
2Depa men o Obs e ics and Gynecology, No h Ka elia Cen al Hospi al, 80210 Joensuu, Finland
3School o Medicine, Uni e si y o Tampe e, 33014 Tampe e, Finland
4Depa men o Psychia y, P¨
aij¨
a -H¨
ame Cen al Hospi al, 15850 Lah i, Finland
Co espondence should be add essed o Pi jo Ke unen; pi jo.k[email p o ec ed]
Recei ed 4 July 2016; Accep ed 29 Sep embe 2016
Academic Edi o : Ve inde Sha ma
Copy igh © 2016 Pi jo Ke unen e al. This is an open access a icle dis ibu ed unde he C ea i e Commons A ibu ion License,
which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed.
In oduc ion. The aim o his s udy is o assess how nega i e li e e en s and ad e se expe iences wi h p egnancy, deli e y, he
in an (s), and b eas eeding cessa ion impac on pos pa um dep ession (PPD), speci ically in i s li e ime and ecu en dep ession.
Me hod. The s udy g oup comp ised 104 mo he s wi h a cu en episode o PPD and a con ol g oup o 104 mo he s who did no
ha e cu en PPD. The S uc u ed Clinical In e iew o DSM-IV Axis I Diso de s (SCID-I) was used o da a collec ion. The
cou se o he dep ession, ad e se expe iences, and b eas eeding we e assessed by sel - epo s. Resul s.Inage-adjus edmul i a ia e
analyses, men al and physical p oblems du ing p egnancy o deli e y, pos pa um p oblems wi h he in an and b eas eeding
cessa ion, and nega i e li e e en s du ing he p e ious 12 mon hs we e associa ed wi h pos pa um dep ession. Eigh een pe cen
(18%) o he mo he s had i s dep ession and 82% ecu en dep ession. Men al and physical p oblems du ing p egnancy o deli e y
we e associa ed wi h bo h i s li e ime and ecu en dep ession. Ne e heless, nega i e li e e en s and in an /b eas eeding issues
associa ed only wi h ecu en dep ession. Conclusion. Fac o s associa ed wi h p egnancy and deli e y ha e an impac on PPD, bu
in ecu en dep ession o he pos na al and psychosocial ac o s a e also impo an isk ac o s.
1. In oduc ion
The pos pa um pe iod is unique wi h espec o he mo he ’s
psychosocial adjus men and he deg ee o physical changes.
Fo mos women, hese expe iences a e cons uc i e and
mo he s a e heal hy. Dep ession a e childbi h, howe e , is
common. The p e alence o pos pa um dep ession (PPD)
is 10–15% [1, 2]. PPD is usually associa ed wi h a p e ious
his o y o dep ession also in p imipa ous women, bu a
subg oup o women may su e dep ession only du ing he
pos pa um pe iod [3–5]. The e is some e idence ha he
occu ence o he i s li e ime episode o dep ession du ing
he pos pa um pe iod is associa ed wi h ad e se e en s du -
ing he p egnancy o deli e y, o wi h he in an [3]. Recu -
en dep essi e episodes may ha e mo e p edisposing ac o s
du ing p egnancy and also psychosocial isk ac o s [3].
S ess ul li e e en s, ad e se expe iences be o e p egnancy,
s ess du ing p egnancy and deli e y, and s ain in in an ca e
in gene al a e connec ed o pos pa um dep ession [2, 6–8].
P egnancy and childbi h a e o en ega ded as s ess ul li e
e en s in hei own igh [8], and childbi h p ocedu es may
ac as a igge o p e ious pain ul memo ies. Pos auma ic
s ess and dep ession a e childbi h seem o be posi i ely
associa ed [9] and sha e he same unde lying ulne abili y
ac o s, such as ea o childbi h, s ess, and psychological
p oblems [9].
Unplanned o unwan ed p egnancy is a p edic o o PPD
[2,7,8].Anunexpec edp egnancymaychange hemo he ’s
li e ex ensi ely and ha e social and economic implica ions;
u he mo e, di icul ies in adjus men o pa en hood may be
g ea e i he p egnancy is no planned [7, 10, 11].
Dep ession and anxie y du ing p egnancy a e signi ican
con ibu o s o PPD [2, 6–9]. Fea o childbi h [3, 9], eelings
Hindawi Publishing Co po a ion
Dep ession Resea ch and T ea men
Volume 2016, A icle ID 2514317, 7 pages
h p://dx.doi.o g/10.1155/2016/2514317
2Dep ession Resea ch and T ea men
o s ess [9, 12], and o he psychological diso de s [6] du ing
p egnancy a e also connec ed o PPD.
P egnancy and deli e y- ela ed (obs e ic) complica ions
also cause physical and men al oubles o he mo he
and comp ise a single p edic o a iable o PPD [2, 6, 8].
Obs e ic ac o s, including p egnancy- ela ed complica ions
such as hype emesis, p eeclampsia, p ema u e con ac ions
and labo , hype ension, headache, pain, anemia, ges a ional
diabe es, diabe es melli us, and amniocen esis [3, 8, 12–15], as
well as deli e y- ela ed complica ions, such as di icul and
pain ul labo , cesa ean sec ion, ins umen al deli e y, p e-
ma u e deli e y, and complica ed pue pe ium-like excessi e
bleeding, ha e been examined as po en ial isk ac o s o
PPD[2,3,8,11].Ina ecen Finnishs udy,cesa eansec ion
was a s ong p edisposing ac o o PPD, speci ically among
hose who had i s li e ime dep ession [3]. The same s udy
ound ha p e e m bi h associa ed wi h i s li e ime dep es-
sion, and anemia and ges a ional diabe es associa ed wi h
ecu en dep ession in he pos pa um pe iod [3]. Acco ding
o se e al s udies, hype emesis is linked wi h an inc eased isk
o dep ession, anxie y, and men al heal h di icul ies [16].
In e ili y ea men does no inc ease he isk o PPD [3, 17].
The associa ion be ween cesa ean sec ion and PPD is
no simple. I is unclea whe he deli e y complica ions o
long and pain ul labo s leading o eme gency p ocedu es
accoun o he associa ion [8, 18]. Women who wan ed
aginal deli e y bu deli e ed by cesa ean sec ion may be
a an inc eased isk o PPD [19]. Con e sely, women who
had been diagnosed wi h a dep essi e diso de a he ime o
deli e y ha e been shown o be signi ican ly mo e likely o
ha eadeli e ybycesa eansec ion[20].
In an - ela ed p oblems a e o en e y s ess ul expe i-
ences o he mo he . Mo he s o p ema u e in an s, mo h-
e s o in an s wi h illnesses/disabili ies/dis ess, mo he s o
in an s ha a e empe amen ally di icul , and mo he s who
expe ience s ain in childca e and ha e a lack o childca e
knowledgea ea isk o de elopingPPD[2,3,7,15].
The ela ionship be ween p oblems wi h he in an and he
mo he ’s dep ession is likely o be complex; o example, he
in e ela ionship be ween p e e m bi h and PPD may be
explained by an in e ac ion o mul iple al e a ions in he labo
and deli e y p ocesses, poo e - han-expec ed in an heal h
ou comes, ea ly pa en al s ess, and dys unc ional mo he -
in an in e ac ion [21, 22]. Speci ically, in an ile colic as a
cause o excessi e and p olonged c ying is a well-known isk
ac o o dep ession [23, 24]. The amoun o in an c ying
is associa ed wi h he expe ience o i edness and a igue in
new mo he s. Inc emen al exhaus ion may igge dep essi e
symp oms, diminish he mo he ’s abili y o concen a e, and
bu den mo he -child in e ac ion [24].
Women who do no o ail o ini ia e b eas eeding a e
a isk o de elopingPPD[2,10,11,25,26].Thee ec o
b eas eeding on dep ession may be media ed by in en ions
o b eas eed. The isk o PPD may be highe among women
whohadplanned ob eas eedand ailed odoso[27].
The ela ionship be ween b eas eeding and PPD seems o be
ecip ocal. B eas eeding educes he isk o de eloping PPD
and con e sely PPD may dec ease he a e o b eas eeding
[10, 26, 28].
The ela ionship be ween s ess ul li e e en s and pos -
pa um dep ession is well known [2, 6, 8]. A numbe o li e
e en s and s esso s a e connec ed o PPD [11, 17, 29–31]. The
mo he ’s own sickness, he sicknesses o dea h o a signi ican
o he , p oblema ic ela ionships, socioeconomic p oblems,
and o he auma ic expe iences seem o be associa ed wi h
dep essi e symp oms du ing he pos pa um pe iod [30, 31].
The pos pa um pe iod seems o be a ime o ulne abili y
o dep ession. An e- and pos na al pe iods p esen unique
challenges in de ec ing he isk ac o s o PPD. The onse o
dep ession may be unexpec ed, and i is use ul o know isk
ac o s o p e en ion and ea men . Li le is known abou
he possible di e ences in isk ac o s o i s li e ime and
ecu en dep ession a e childbi h. The aim o his s udy is
o assess how p egnancy and deli e y issues, issues ela ing
o he in an and b eas eeding cessa ion, and nega i e li e
e en s associa e wi h pos pa um dep ession. In addi ion, he
s udy seeks o disco e i he e a e di e ences in hei ole
be ween i s li e ime dep ession and ecu en dep ession
du ing he pos pa um pe iod.
2. Ma e ials and Me hods
The na u e o his s udy is c oss-sec ional. Bo h he s udy
g oup (dep essed) and he con ol g oup (nondep essed)
consis ed o 104 mo he s e alua ed six weeks o six mon hs
a e deli e y. Mo he s we e ec ui ed by p ima y heal h ca e
nu ses a an ena al clinics in Joensuu, a own in Eas e n Fin-
land, using he Edinbu gh Pos na al Dep ession Scale (EPDS,
ange: 0–30) [32]. I he EPDS sco e was ≥10 o he e was
clinical suspicion o dep ession, he nu ses old he mo he
ha she could be assessed by a psychia is (Pi jo Ke unen)
a he local Gene al Hospi al Psychia ic Uni a No h Ka elia
Cen al Hospi al, Joensuu, Finland. This communi y-based
hospi al uni se es a socioeconomically di e se popula ion.
Mo he s we e ca ed o a he Obs e ic Depa men a he
same hospi al du ing p egnancy and deli e y (app oxima ely
1,550 deli e ies pe yea ). Da a collec ion ook place om
2003 o 2013. I he EPDS sco e was <10 and he e was no
clinical suspicion o dep ession, p ima y heal h ca e nu ses
asked mo he s i hey we e willing o pa icipa e in he s udy
as pa o he con ol g oup and hen o ganized a psychia ic
assessmen a he an ena al clinics. The con ol g oup was
collec ed be ween 2008 and 2010.
The diagnoses o majo dep essi e diso de in he s udy
g oup (dep essed mo he s) and he con ol g oup (non-
dep essed mo he s) we e assessed by a psychia is (Pi jo
Ke unen) by means o he S uc u ed Clinical In e iew
o DSM-IV (Diagnos ic and S a is ical Manual o Men al
Diso de s, ou h edi ion) Axis I Diso de s (SCID-I) [33].
A endees wi h psycho ic, addic i e, and hy oid diso de s
we e excluded. Women aged 18–40 yea s we e included. The
mo he s we e also e alua ed by he psychia is (Pi jo Ke -
unen) using a semis uc u ed in e iew designed o iden i y
isk ac o s ela ing o p egnancy, deli e y, he in an , b eas -
eeding, and li e e en s du ing he p e ious yea .
P e ious dep essi e episodes we e assessed by asking
whe he he mo he s had had dep ession las ing o
Dep ession Resea ch and T ea men 3
a leas wo weeks; he ime pe iod was in line wi h
DSM-IV[33].Mo he swe ealsoaskedhowold hey
we e and how many child en, ges a ions, deli e ies,
spon aneous o induced abo ions, and s illbi hs
hey had had.
Mo he s we e asked abou possible isk ac o s:
(i) I he p egnancy was wan ed o unwan ed o i he
mo he could no say. Answe s we e classi ied as wan -
ed (“yes”) o unwan ed (“no” o “canno say”).
(ii) I hey had had dep ession las ing o a leas wo weeks
du ing p egnancy. Responses we e “yes” o “no.”
(iii) I he e had been o he men al symp oms han dep es-
sion du ing p egnancy and wha he symp oms we e.
Fea s we e classi ied in o one g oup, and o he men-
al symp oms (anxie y, panic, obsessions, insomnia,
a igue, ea ulness, sensi i i y, psychosoma ic symp-
oms, headache, and loss o appe i e) we e classi ied
in o a second, miscellaneous g oup. This ca ego iza-
ionisbasedon he ac ha ea s,especiallya ea o
childbi h, a e speci ic con ibu o s o PPD [3, 9].
(i ) I hey had had a complica ed p egnancy and wha
he complica ions we e. The complica ions we e clas-
si ied as hype emesis and miscellaneous p egnancy-
ela ed complica ions (pain, diabe es melli us, ane-
mia, oxemia, p eeclampsia, hepa oges osis, p u i us,
p ema u e con ac ions, in ec ion, aginal bleeding,
and small- o -da e in an ) and in e ili y ea men .
Classi ica ion was based on he di e en na u e o
hese di icul ies. Fo example, hype emesis is linked
wi h a b oad spec um o men al symp oms and dis-
o de s [16], and in e ili y ea men [3, 17] associa es
wi h dis ess be o e and du ing ea ly p egnancy.
( ) I hey had had a complica ed deli e y and wha he
complica ions we e. The complica ions we e classi-
ied as pain ul labo and miscellaneous complica-
ions du ing deli e y (no con ac ions, leng hy labo ,
ins umen al deli e y, excessi e bleeding, in ec ion,
eme gency cesa ean sec ion, and a igue). Ca ego iza-
ion was based on he ac ha pain is an especially
common discom o du ing deli e y [2, 18]. Mode
o deli e y ( aginal, elec i e cesa ean sec ion, o
eme gency cesa ean sec ion) was also asked.
( i) I he in an has had sicknesses o symp oms and wha
he sicknesses o symp oms we e. The answe s we e
classi ied as colic, e al abno mali ies, and o he s (ea -
ing p oblems, b ea hing p oblems, in ec ions, and al-
le gy). In an ile colic is a common bu den o mo he s
[23, 24]. Fe al abno mali ies a e much a e and seem
obespeci icp oblems o somemo he s[3].
( ii) I hey we e b eas eeding. Responses we e “yes” o
“no.”
( iii) I hey had expe ienced nega i e li e e en s du ing he
p e ious 12 mon hs and wha hese e en s we e. Neg-
a i e li e e en s we e classi ied as a dea h o a signi -
ican o he (own o pa ne ’s pa en s, g andpa en s,
siblings, o iends), own o signi ican o he ’s sick-
ness (husband, pa en s, o siblings), socioeconomic
p oblems (unemploymen , p oblems a wo k, housing
p oblems, economic ha dship, o academic di icul-
ies), and p oblems in close ela ionships (b eakdown
o ela ionship o own o pa en s’ di o ce). This ca -
ego iza ion loosely esembles ha used by Ahluwalia
e al. [34].
The s udy p o ocol was app o ed by he E hical Commi -
ee o he No h Ka elian Hospi al Dis ic Fede a ion o
Municipali ies. All pa icipan s ga e hei in o med consen
o pa icipa e in his s udy p io o da a collec ion.
Da a analysis was ca ied ou wi h IBM SPSS S a is ics
( e sion 22). To assess he di e ences be ween he s udy
g oups,alsoin ela ion o hecou seo dep ession,Pea son’s
chi-squa ed es and Fishe ’s exac es we e used o he
ca ego ical a iables and independen samples 𝑡- es was used
o he con inuous a iables. I a con inuous a iable was
no no mally dis ibu ed, a nonpa ame ic Mann–Whi ney
𝑈 es was used. A 𝑝 alue less han 0.05 deno ed s a is ical
signi icance. The ela ionships be ween isk ac o s and PPD,
also in ela ion o he cou se o dep ession, we e also in-
es iga ed using logis ic eg ession. The inal age-adjus ed
logis ic eg ession model included con inuous sum a i-
ables “p egnancy and deli e y issues” (unwan ed p egnancy,
dep ession and/o o he men al symp oms du ing p egnancy,
complica ed p egnancy, and complica ed deli e y including
bo h aginal deli e y and complica ed cesa ean sec ion) and
“issues ela ing in an and b eas eeding cessa ion” (in an ’s
symp oms and illnesses and b eas eeding cessa ion). Nega-
i e li e e en s du ing he p e ious 12 mon hs we e classi ied
as a bina y a iable (no = 0; yes = 1).
3. Resul s
The s udy g oup consis ed o 104 mo he s wi h a majo
dep essi e diso de and a con ol g oup o 104 nondep essed
mo he s.
The mean age o he in an s was 82.9 days (s anda d
de ia ion (SD) 33.5) in he dep ession g oup and 80.2 days
(SD 19.3) in he nondep essed g oup (𝑝 = 0.36). Dep essed
mo he s we e younge han nondep essed mo he s (mean
27.4 yea s (SD 5.3) e sus 29.6 yea s (SD 4.1), 𝑝 = 0.001).
Fi y- h ee (51.0%) mo he s in he dep essed g oup had
deli e ed hei i s child, as had 48 (46.2%) mo he s in he
nondep essed g oup (𝑝 = 0.49). No di e ence was ound in
he mean numbe o child en (mean 1.7 (SD 0.9) e sus 1.8
(SD 0.9), 𝑝 = 0.67, esp.). The mean numbe o ges a ions
was 2.0 (SD 1.3) in he dep essed g oup and 2.1 (SD 1.2) in
he nondep essed g oup (𝑝 = 0.68). No pa icipan had had
a s illbi h. The e we e no di e ences be ween he g oups in
ega d o he numbe o mo he s wi h p e ious spon aneous
abo ion (23 (22.1%) e sus 18 (17.3%), 𝑝 = 0.383)o induced
abo ion (7 (6.7%) e sus 9 (8.7%), 𝑝 = 0.60).
Unwan ed p egnancy, dep ession, ea s, and o he men al
symp oms du ing p egnancy we e signi ican ly mo e com-
mon among he dep essed han he nondep essed mo he s
(Table 1). P egnancy- ela ed p oblems we e as common in
4Dep ession Resea ch and T ea men
Table 1: Ad e se expe iences du ing he an ena al and pos na al pe iod in he nondep essed and dep essed g oup.
Nondep essed g oup Dep essed g oup 𝑝 alue5
𝑁 = 104 𝑁 = 104
𝑛%𝑛%
Unwan ed p egnancy 6 5.8 21 20.4 0.002
Dep ession du ing p egnancy 5 4.8 44 42.3 <0.001
Men al symp oms du ing p egnancy excl. dep ession 12 11.5 35 33.7 <0.001
(i) Fea s 3 2.9 11 10.6 0.027
(ii) Miscellaneous19 8.7 27 26.0 0.001
Complica ed p egnancy 44 42.3 50 48.1 0.403
(i) Hype emesis 4 3.8 15 14.4 0.008
(ii) P egnancy complica ions241 39.4 42 40.4 0.887
(iii) In e ili y ea men 4 3.8 1 1.0 0.3666
Complica ed deli e y 31 29.8 46 44.7 0.031
(i) Pain 7 6.7 20 19.2 0.007
(ii) Miscellaneous324 23.1 27 26 0.629
In an ’s symp oms and illnesses 14 13.5 32 30.8 0.003
(i) In an ile colic 6 5.8 17 16.3 0.015
(ii) Fe al abno mali ies 4 3.8 5 4.8 1.0006
(iii) Miscellaneous44 3.8 10 9.6 0.097
B eas eeding cessa ion 18 17.3 40 38.5 0.001
Nega i e li e e en s 27 26.0 47 45.2 0.004
(i) Dea h o signi ican o he s 12 11.5 13 12.5 0.831
(ii) Sickness (own o signi ican o he s) 8 7.7 16 15.4 0.083
(iii) Rela ionship p oblems 5 4.8 17 16.3 0.007
(i ) Socioeconomic p oblems 4 3.8 8 7.7 0.234
1Anxie y, panic, obsessions, insomnia, a igue, ea ulness, sensi i i y, psychosoma ic symp oms, headache, and loss o appe i e. 2Pain, diabe es melli us,
anemia, oxemia, p eeclampsia, hepa oges osis, p u i us, p ema u e con ac ions, in ec ion, aginal bleeding, and small- o -da e in an . 3No con ac ions,
leng hy labo , ins umen al deli e y, excessi e bleeding, in ec ion, eme gency sec ion, and a igue. 4Ea ing p oblems, b ea hing p oblems, in ec ions, and
alle gy. 5Pea son’s chi-squa e es . 6Fishe ’s exac es .
bo h g oups (Table 1). Ne e heless, hype emesis was mo e
common among he dep essed han he nondep essed mo h-
e s. Complica ed deli e y—speci ically pain—was signi i-
can ly mo e common among he dep essed han he non-
dep essed con ols (Table 1). The e we e no di e ences be-
ween g oups wi h ega d o me hod o he deli e y
(dep essed/nondep essed: aginal deli e y 87 (83.7%) e sus
90 (86.5%), 𝑝 = 0.559,elec i esec ion7(6.7%) e sus10
(9.6%), 𝑝 = 0.448, and eme gency sec ion 10 (9.6%) e sus
4 (3.8%), 𝑝 = 0.097).
In an s su e ing om symp oms and illnesses, especially
om in an ile colic, we e mo e common among dep essed
han nondep essed mo he s (Table 1). Cessa ion o b eas -
eeding was mo e common in dep essed mo he s.
Nega i e li e e en s du ing he p e ious 12 mon hs we e
mo e common among dep essed mo he s han among he
nondep essed con ols (Table 1). Speci ically, complica ed
close ela ionships we e mo e common among dep essed
mo he s.
The numbe o isk ac o s was highe in he dep essed
han in he nondep essed g oup (Table 2). Eigh een pe cen
(18.2%: 19/104) o he mo he s we e expe iencing hei i s
dep ession and 81.7% (85/104) ecu en dep ession. Six y-
nine pe cen (69.2%: 72/104) o nondep essed mo he s had
no p e ious dep ession. The mean numbe o isk ac o s was
Table 2: Numbe o isk ac o s in he nondep essed and dep essed
g oup.
Numbe o
isk ac o s1
Nondep essed g oup Dep essed g oup
𝑁 = 104 𝑁 = 104
𝑛%𝑛%
02221.243.8
13735.61514.4
2 28 26.9 23 22.1
3 7 6.7 26 25.0
487.72524.0
5 2 1.9 7 6.7
60032.9
70011.0
Mean2=1.50 SD=1.23 Mean
2=2.87 SD=1.44
1Unwan ed p egnancy, dep ession and/o o he men al symp oms du ing
p egnancy, complica ed p egnancy, complica ed deli e y, in an ’s symp oms
and illnesses, b eas eeding cessa ion, and nega i e li e e en s du ing he
p e ious 12 mon hs. 2Mann–Whi ney 𝑈 es : 𝑝 < 0.001.SD=s anda d
de ia ion.
highe among mo he s wi h i s li e ime dep ession (𝑛=19)
han among he ne e -dep essed con ol g oup (𝑛=72;mean
Dep ession Resea ch and T ea men 5
Table 3: Age-adjus ed isk o ha ing pos pa um dep ession acco ding o mul i a ia e logis ic eg essions in ela ion o he cou se o
dep ession.
Dep essed (𝑛 = 104) e sus
nondep essed mo he s (𝑛 = 104)
Mo he s wi h i s li e ime
dep ession (𝑛=19) e sus
ne e -dep essed con ols (𝑛=72)
Mo he s wi h ecu en dep ession
(𝑛=85) e sus ne e -dep essed
con ols (𝑛=72)
OR195% CI2𝑝 alue OR195% CI2𝑝 alue OR195% CI2𝑝 alue
P egnancy and
deli e y issues
(𝑛3=4)
2.31 1.59–3.35 <0.001 2.87 1.33–6.17 0.007 2.88 1.81–4.59 <0.001
Issues ela ing in an
and b eas eeding
cessa ion (𝑛4=2)
1.86 1.11–3.09 0.018 2.27 0.96–5.35 0.062 2.17 1.14–4.13 0.019
Nega i e li e e en s
(no e sus yes) 2.16 1.12–4.16 0.021 1.00 0.28–3.58 1.000 2.51 1.15–5.50 0.021
1OR = odds a io. 295%CI = 95%con idence in e al. 3Unwan ed p egnancy, dep ession and/o o he men al symp oms du ing p egnancy, complica ed
p egnancy, and complica ed deli e y. 4In an ’s symp oms and illnesses and b eas eeding cessa ion.
2.58 (SD 1.46) e sus mean 1.32 (SD 1.11), 𝑝 < 0.001, esp.).
Simila ly, mo he s wi h ecu en dep ession (𝑛=85)had
mo e isk ac o s han hei ne e -dep essed coun e pa s
(𝑛=72; mean 2.94 (SD 1.43) e sus 1.32 (SD 1.11), 𝑝 < 0.001,
esp.). The e was no di e ence be ween g oups wi h ega d o
i s li e ime (𝑛=19) and ecu en dep ession (𝑛=85;mean
2.58 (SD 1.46) e sus mean 2.94 (SD 1.43), 𝑝 = 0.247, esp.).
P egnancy and deli e y issues, issues ela ing o he in an
andb eas eeding,andnega i eli ee en sdu ingp e ious12
mon hs we e associa ed wi h PPD acco ding o age-adjus ed
logis ic eg ession (Table 3). P egnancy and deli e y issues
associa ed wi h bo h he isk o i s li e ime dep ession
and he isk o ecu en dep ession when compa ed o he
ne e -dep essed con ol g oup. Ne e heless, issues ela ed
o he in an and b eas eeding cessa ion and nega i e li e
e en s associa ed only wi h he isk o ecu en dep ession
(Table 3). In a subg oup o mo he s who had had a leas one
p e ious dep essi e episode, nega i e li e e en s du ing he
p e ious 12 mon hs we e a signi ican isk ac o o PPD (OR
2.60, 95% CI 1.00–6.75, and 𝑝 = 0.049). No di e ences we e
ound in he nondep essed con ol g oup be ween mo he s
wi h no his o y o dep ession and a his o y o p e ious
dep essions (da a no shown).
4. Discussion
In gene al, men al and physical p oblems du ing p egnancy
o deli e y, pos pa um p oblems wi h he in an and b eas -
eeding cessa ion, and nega i e li e e en s du ing he p e ious
12 mon hs we e connec ed o PPD. Men al and physical
p oblems du ing p egnancy o deli e y we e associa ed wi h
bo h i s li e ime dep ession and ecu en dep ession du ing
he pos pa um pe iod. Fu he mo e, o ecu en dep es-
sion, in an /b eas eeding issues and nega i e li e e en s we e
also isk ac o s. The di e ences in isk ac o s be ween i s
li e ime and ecu en majo dep essi e episodes du ing he
pos pa um pe iod ep esen a no el inding o his s udy.
The isk o ecu en dep ession is independen ly associa ed
wi hmo e isk ac o so lesse se e i y o hemo he ’sheal h
compa ed o he isk o i s li e ime dep ession. This means
ha du ing he pos pa um pe iod a ecu en episode o
dep ession may esul om less se e e s ess exposu e han
he i s li e ime episode, which is in line wi h he kindling
hypo hesis [35]. Among mo he s who had expe ienced a
p e ious dep essi e episode, ecen nega i e li e e en s we e
o pa icula impo ance.
In ou s udy, unwan ed p egnancy and an indi e en
a i ude o p egnancy we e connec ed o dep ession. An un-
wan ed p egnancy may change li e conside ably, be a s ess ul
expe ience wi h social and economic changes, and u he
impac on di icul ies wi h mo he hood [2, 7, 8, 10].
Acco ding o ou s udy, dep ession and o he men al
symp oms du ing p egnancy a e impo an isk ac o s o
PPD. This associa ion has been ound in nume ous p e ious
s udies [2, 6–9]. In ou s udy, ea s we e emphasized, and
hese we e linked widely o he p esen li e si ua ion, no only
o childbi h, as is usually s udied [3, 9]. Findings om o he
s udies sugges ha p egnancy- ela ed complica ions a e in
gene alpo en ial isk ac o s o PPD[2,3,8,12,14,15],bu
inou s udyonlyhype emesisasaspeci icp egnancycom-
plica ion associa ed wi h PPD. No su p isingly, hype emesis
has been linked wi h dep ession, anxie y, and men al heal h
di icul ies in o he s udies [8, 13, 16].
Ou s udy ound ha complica ed deli e y, especially
pain du ing deli e y, is connec ed o dep ession. O he
s udies [2, 8, 18] ha e shown mixed indings ega ding he link
be ween deli e y complica ions and PPD.
Cesa ean sec ion (elec i e and eme gency) was equally
as common among dep essed and nondep essed mo he s, as
se e al p e ious s udies ha e sugges ed [2, 8]. Pe haps he
pain and o he complica ions du ing deli e y a e mo e e-
ma kable easons o dep ession han he me hod o deli e y
[2,8,18].
In an - ela ed p oblems a e well-known isk ac o s o
PPD[2,3,7,15,22].We ound ha in an symp omsand
sicknesses we e connec ed o dep ession. Acco ding o ou
s udy, he main cause o his is in an ile colic wi h uncon-
olled c ying [23, 24]. In an c ying is associa ed wi h he
mo he ’s i edness and may ac as a igge o dep ession
[24]. Ou s udy, like p e ious s udies [2, 11, 25, 26, 28], shows

6Dep ession Resea ch and T ea men
ha dep essed mo he s mo e commonly ha e b eas eeding
cessa ions. The e ec o b eas eeding cessa ion on dep ession
may be media ed h ough poo sel -es eem by ailed in en-
ions o b eas eed [10, 11, 27]. Al e na i ely, dep essed women
maygi eupb eas eedingmo e eadily[10,26,28].
We ound ha nega i eli ee en sdu ing hep e ious
12 mon hs we e common among dep essed mo he s, which
is in line wi h se e al p e ious s udies [2, 6, 8, 11, 17, 29–
31]. Ou s udy highligh ed he ole o p oblema ic ela ion-
ships. When i s li e ime and ecu en dep essi e episodes
we e s udied sepa a ely, an associa ion was ound only wi h
ecu en dep essions. This sugges s ha p e ious p oblems
in ela ionships migh associa e wi h p e ious dep essions.
I may e en be ha p e ious p oblems in ela ionships and
p e ious dep essions ha e an addi i e impac on he isk o
PPD.
No su p isingly, he numbe o isk ac o s was highe
among dep essed han nondep essed mo he s. Fu he mo e,
he numbe o isk ac o s was also highe among mo he s
wi h i s li e ime dep ession o ecu en dep ession du ing
he pos pa um pe iod han among nondep essed mo he s
wi hou a his o y o dep ession. A numbe o s esso s ha e
also been connec ed o PPD in o he s udies [11, 17, 29–31].
The limi a ions o his s udy include he e ospec i e
sel - epo o p e ious dep essions and expe iences o li e
e en s, p egnancy, deli e y, and he in an . Mo he s may
downplay o exagge a e hei esponses acco ding o hei
belie s and pe cep ions, and in he mids o a dep essi e
episode hei hough s may be nega i e abou he sel and he
en i onmen [36]. I is possible ha mo he s do no ecognize
hei symp oms and diso de s. The h ea o in e nal alidi y
isalso he ac ha hesampling imewaslonge in he
dep essed han in he nondep essed g oup. Ne e heless, he
dep essed g oup and he con ol g oup ep esen he same
socioeconomically di e se popula ion. Mo he s a ended he
same obs e ic clinic, and he heal h se ices we e s able du -
ing he sampling ime. Fu he mo e, he use o a con enience
sampling me hod limi s he gene alizabili y o he b oade
popula ion. We could only e alua e dep essed mo he s who
accep ed an in i a ion om he p ima y heal h ca e nu ses
o a end a psychia ic in e iew. The c oss-sec ional na u e
o his s udy limi s he assessmen o causali y. The small
numbe o cases inc eased he isk o ype II s a is ical
e o , so ue di e ences may no ha e been de ec ed. The e
may also be in e co ela ions be ween a iables. A u he
limi a ion is he ac ha he psychia is (Pi jo Ke unen)
conduc ing he semis uc u ed in e iews was no blind o
he mo he s’ dep ession s a us. The diagnos ic in e iew
cons i u es a c i ical s eng h o he s udy. The diagnoses o
majo dep essi e diso de in he s udy g oup and con ol
g oup we e made by he psychia is using he S uc u ed
Clinical In e iew o DSM-IV Axis I Diso de s.
5. Conclusions
In conclusion, men al and physical p oblems du ing p eg-
nancyo deli e yha eanimpac onbo h i s li e imeand
ecu en PPD. Ne e heless, in ecu en dep ession, ad e se
expe iences wi h he in an and b eas eeding cessa ion and
nega i e li e e en s a ound he ime o ha ing a baby
also ha e an impo an impac . Compa ed o nondep essed
mo he s, dep essed mo he s ha e mo e ad e se expe iences.
O pa icula impo ance o conside a ion a e p oblema ic
ela ionships, unwan ed p egnancy, dep ession, ea s and
o he men al symp oms du ing p egnancy, hype emesis, pain
du ing deli e y, and in an ile colic. To be able o p e en and
ca e o PPD in clinical p ac ice, i is necessa y o discuss he
mo he ’s s ess ac o s wi h he . P egnancy planning, men-
alsymp omsdu ingp egnancy,and ela ionshipp oblems
should be conside ed. I is impo an o handle hype emesis
and deli e y pain well, suppo women in ca ing o babies
wi h colic, and p o ide expe suppo o women who ha e
di icul ies wi h b eas eeding. I a mo he has expe ienced
p e ious dep ession, i is especially impo an o ake nega i e
li e e en s in o accoun .
Compe ing In e es s
The au ho s decla e ha he e is no con lic o in e es s
ega ding he publica ion o his pape .
Acknowledgmen s
This s udy was suppo ed (Pi jo Ke unen) wi h an EVO (spe-
cial s a e unding) g an om No h Ka elia Cen al Hospi al
and a g an om he Finnish Psychia ic Associa ion. The
au ho s wish o hank he p ima y heal h ca e nu ses a he
an ena al clinics in Joensuu o ec ui ing he pa icipan s o
he psychia ic assessmen s.
Re e ences
[1] N. I. Ga in, B. N. Gaynes, K. N. Loh , S. Mel ze -B ody, G.
Ga lehne , and T. Swinson, “Pe ina al dep ession: a sys ema ic
e iew o p e alence and incidence,” Obs e ics & Gynecology,
ol.106,no.5,pa 1,pp.1071–1083,2005.
[2] M.N.No haya i,N.H.NikHazlina,A.R.As enee,andW.M.A.
Wan Emilin, “Magni ude and isk ac o s o pos pa um symp-
oms: a li e a u e e iew,” Jou nal o A ec i e Diso de s, ol.175,
pp.34–52,2015.
[3] S. R¨
ais¨
anen,S.M.Leh o,H.S.Nielsen,M.Gissle ,M.R.K ame ,
and S. Heinonen, “Fea o childbi h p edic s pos pa um
dep ession: a popula ion-based analysis o 511 422 single on
bi hs in Finland,” BMJ Open, ol. 3, a icle 11, 2013.
[4] P. J. Coope and L. Mu ay, “Cou se and ecu ence o pos -
na al dep ession e idence o he speci ici y o he diagnos ic
concep ,” The B i ish Jou nal o Psychia y, ol.166,pp.191–195,
1995.
[5] P. Ke unen, E. Kois inen, and J. Hin ikka, “Is pos pa um de-
p ession a homogenous diso de : ime o onse , se e i y, symp-
oms and hopelessness in ela ion o he cou se o dep ession,”
BMC P egnancy and Childbi h, ol.14,no.1,a icle402,2014.
[6] M. W. O’Ha a and A. M. Swain, “Ra es and isk o pos pa um
dep ession—a me a-analysis,” In e na ional Re iew o Psychia-
y, ol.8,no.1,pp.37–54,1996.
[7] C. T. Beck, “P edic o s o pos pa um dep ession: an upda e,”
Nu sing Resea ch, ol.50,no.5,pp.275–285,2001.
[8]E.Robe son,S.G ace,T.Walling on,andD.E.S ewa ,
“An ena al isk ac o s o pos pa um dep ession: a syn hesis
Dep ession Resea ch and T ea men 7
o ecen li e a u e,” Gene al Hospi al Psychia y, ol.26,no.4,
pp.289–295,2004.
[9] J. S¨
ode quis , B. Wijma, G. Tho be , and K. Wijma, “Risk ac-
o s in p egnancy o pos - auma ic s ess and dep ession a e
childbi h,” BJOG: An In e na ional Jou nal o Obs e ics and
Gynaecology, ol.116,no.5,pp.672–680,2009.
[10]R.Wa ne ,L.Appleby,A.Whi on,andB.Fa aghe ,“Demo-
g aphic and obs e ic isk ac o s o pos na al psychia ic mo -
bidi y,” B i ish Jou nal o Psychia y, ol.168,pp.607–611,1996.
[11] S. El-Sayed, W. El-Bahei, M. del El-Hadi y, and A. Zayed, “P e-
dic o s o pos pa um dep ession in a sample o Egyp ian
women,” Neu opsychia ic Disease and T ea men , ol.9,pp.15–
24, 2013.
[12] R.K.Gi i,R.B.Kha i,S.R.Mish a,V.Khanal,V.D.Sha ma,
and R. P. Ga oula, “P e alence and ac o s associa ed wi h
dep essi e symp oms among pos -pa um mo he s in Nepal,”
BMC Resea ch No es, ol. 8, no. 1, a icle 111, 2015.
[13]A.Jose sson,L.Angelsi
¨
o¨
o, G. Be g e al., “Obs e ic, soma ic,
and demog aphic isk ac o s o pos pa um dep essi e symp-
oms,” Obs e ics and Gynecology, ol.99,no.2,pp.223–228,
2002.
[14] K. B. Kozhimannil, M. A. Pe ei a, and B. L. Ha low, “Associa ion
be ween diabe es and pe ina al dep ession among low-income
mo he s,” JAMA-Jou nal o he Ame ican Medical Associa ion,
ol. 301, no. 8, pp. 842–847, 2009.
[15] S. N. Vigod, L. Villegas, C.-L. Dennis, and L. E. Ross, “P e a-
lence and isk ac o s o pos pa um dep ession among women
wi h p e e m and low-bi h-weigh in an s: a sys ema ic e iew,”
BJOG: An In e na ional Jou nal o Obs e ics and Gynaecology,
ol.117,no.5,pp.540–550,2010.
[16] F.P.McCa hy,J.E.Lu omski,andR.A.G eene,“Hype eme-
sis g a ida um: cu en pe spec i es,” In e na ional Jou nal o
Women’s Heal h, ol.6,no.1,pp.719–725,2014.
[17] C. D. Lynch and M. R. P asad, “Associa ion be ween in e ili y
ea men and symp oms o pos pa um dep ession,” Fe ili y
and S e ili y, ol.102,no.5,pp.1416–1421,2014.
[18] J.C.Eisenach,P.H.Pan,R.Smiley,P.La and’homme,R.Lan-
dau,andT.T.Houle,“Se e i yo acu epaina e childbi h,
bu no ype o deli e y, p edic s pe sis en pain and pos pa um
dep ession,” Pain, ol.140,no.1,pp.87–94,2008.
[19] K. A. Hous on, A. J. Kaimal, S. Nakagawa, S. E. G ego ich, L. M.
Yee, and M. Kuppe mann, “Mode o deli e y and pos pa um
dep ession: he ole o pa ien p e e ences,” Ame ican Jou nal o
Obs e ics and Gynecology, ol.212,no.2,pp.229–231,2015.
[20] P.Bansil,E.V.Kuklina,S.F.Meiklee al.,“Ma e naland e al
ou comes among women wi h dep ession,” Jou nal o Women’s
Heal h, ol.19,no.2,pp.329–334,2010.
[21] D. H. B andon, K. P. Tully, S. G. Sil a e al., “Emo ional e-
sponses o mo he s o la e-p e e m and e m in an s,” Jou nal
o Obs e ic, Gynecologic, & Neona al Nu sing, ol.40,no.6,pp.
719–731, 2011.
[22]S.S.Gulamani,S.S.P emji,Z.K.Kanji,andS.I.Azam,“A
e iew o pos pa um dep ession, p e e m bi h, and cul u e,”
TheJou nalo Pe ina alandNeona alNu sing, ol.27,no.1,pp.
52–59, 2013.
[23] T.Vik,V.G o e,J.Esc ibanoe al.,“In an ilecolic,p olonged
c ying and ma e nal pos na al dep ession,” Ac a Paedia ica,
ol. 98, no. 8, pp. 1344–1348, 2009.
[24] E. Ku h, H. P. Kennedy, E. Spichige , I. H¨
osli, and E. Zemp
S u z, “C ying babies, i ed mo he s: wha do we know? A
sys ema ic e iew,” Midwi e y, ol.27,no.2,pp.187–194,2011.
[25] E. Ys om, “B eas eeding cessa ion and symp oms o anxie y
and dep ession: a longi udinal coho s udy,” BMC P egnancy
and Childbi h, ol.12,a icle36,2012.
[26] B. Figuei edo, C. C. Dias, S. B and˜
ao,C.Can
´
a io, and R. Nunes-
Cos a, “B eas eeding and pos pa um dep ession: s a e o he
a e iew,” Jo nal de Pedia ia, ol.89,no.4,pp.332–338,2013.
[27] C. Bo a, M. Iaco ou, and A. Se illa, “New e idence on b eas -
eeding and pos pa um dep ession: he impo ance o unde -
s anding women’s in en ions,” Ma e nal and Child Heal h Jou -
nal, ol.19,no.4,pp.897–907,2015.
[28] A. Hamdan and H. Tamim, “The ela ionship be ween pos pa -
um dep ession and b eas eeding,” The In e na ional Jou nal o
Psychia y in Medicine, ol.43,no.3,pp.243–259,2012.
[29] C. Rube sson, B. Wickbe g, P. Gus a sson, and I. R˚
ades ad,
“Dep essi e symp oms in ea ly p egnancy, wo mon hs and one
yea pos pa um-p e alence and psychosocial isk ac o s in a
na ional Swedish sample,” A chi es o Women’s Men al Heal h,
ol. 8, no. 2, pp. 97–104, 2005.
[30] J. Yelland, G. Su he land, and S. J. B own, “Pos pa um anxie y,
dep ession and social heal h: indings om a popula ion-based
su ey o Aus alian women,” BMC Public Heal h, ol.10,a icle
771, 2010.
[31] S.L.S one,H.Diop,E.Decle cq,H.J.Cab al,M.P.Fox,and
L. A. Wise, “S ess ul e en s du ing p egnancy and pos pa um
dep essi e symp oms,” Jou nal o Women’s Heal h, ol.24,no.5,
pp. 384–393, 2015.
[32] J. L. Cox, J. M. Holden, and R. Sago sky, “De ec ion o pos na al
dep ession: de elopmen o he 10-i em Edinbu gh pos na al
dep ession scale,” The B i ish Jou nal o Psychia y, ol.150,pp.
782–786, 1987.
[33]M.B.Fi s ,R.L.Spi ze ,M.Gibbon,andJ.B.W.Williams,
S uc u ed Clinical In e iew o DSM-IV Axis I Diso de s,
Resea ch Ve sion, Non-Pa ien Edi ion, New Yo k S a e Psychi-
a ic Ins i u e, Biome ics Resea ch, New Yo k, NY, USA, 2002.
[34] I. B. Ahluwalia, R. Me i , L. F. Beck, and M. Roge s, “Mul iple
li es yle and psychosocial isks and deli e y o small o ges a-
ional age in an s,” Obs e ics & Gynecology, ol.97,no.5,pp.
649–656, 2001.
[35] R. M. Pos , “T ansduc ion o psychosocial s ess in o he neu-
obiology o ecu en a ec i e diso de ,” The Ame ican Jou nal
o Psychia y, ol.149,no.8,pp.999–1010,1992.
[36] A. T. Beck, Cogni i e The apy and he Emo ional Diso de s,In-
e na ional Uni e si ies P ess, New Yo k, NY, USA, 1976.
Submi you manusc ip s a
h p://www.hindawi.com
S em Cells
In e na ional
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
MEDIATORS
INFLAMMATION
o
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Beha iou al
Neu ology
Endoc inology
In e na ional Jou nal o
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Disease Ma ke s
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
BioMed
Resea ch In e na ional
Oncology
Jou nal o
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Oxida i e Medicine and
Cellula Longe i y
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
PPAR Resea ch
The Scien i ic
Wo ld Jou nal
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Immunology Resea ch
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Jou nal o
Obesi y
Jou nal o
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Compu a ional and
Ma hema ical Me hods
in Medicine
Oph halmology
Jou nal o
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Diabe es Resea ch
Jou nal o
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Resea ch and T ea men
AIDS
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Gas oen e ology
Resea ch and P ac ice
Hindawi Publishing Co po a ion
h p://www.hindawi.com Volume 2014
Pa kinson’s
Disease
E idence-Based
Complemen a y and
Al e na i e Medicine
Volume 2014
Hindawi Publishing Co po a ion
h p://www.hindawi.com