Observational Study Open Access
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatry. Aug 19, 2022; 12(8): 1061-1075
Published online Aug 19, 2022. doi: 10.5498/wjp.v12.i8.1061
Peripartum depression and its predictors: A longitudinal observational hospital-based study
Sherifa Ahmed Hamed, Mohamed Elwasify, Mohamed Abdelhafez, Mohamed Fawzy
Sherifa Ahmed Hamed, Mohamed Fawzy, Department of Neurology and Psychiatry, Assiut University Hospital, Assiut 71516, Egypt
Mohamed Elwasify, Department of Psychiatry, Mansoura University, Mansoura 11001, Egypt
Mohamed Abdelhafez, Department of Obstetrics and Gynecology, Mansoura University, Mansoura 11001, Egypt
ORCID number: Sherifa Ahmed Hamed (0000-0002-1441-3530); Mohamed Elwasify (0000-0002-2983-8398); Mohamed Abdelhafez (0000-0001-5219-1214); Mohamed Fawzy (0000-0001-7732-2946).
Author contributions: Hamed SA and Fawzy M carried out design of the study, statistical analyses, and manuscript drafting; Elwasify M and Abdelhafez M did the clinical evaluation of participants and participated in study design and drafting the manuscript; All authors read and approved the final manuscript.
Institutional review board statement: The ethics Committees of Faculties of Medicine of Mansoura and Assiut Universities, Mansoura and Assiut Governorates, Egypt; approved the study protocol. Women gave their informed consents for participation in the study, No. AUFM_NP/OG_422/2016.
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: This study has no data to be shared.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sherifa Ahmed Hamed, MD, Professor, Department of Neurology and Psychiatry, Assiut University Hospital, Assiut University Street, Assiut 71516, Egypt. hamedsherifa@aun.edu.eg
Received: October 4, 2021
Peer-review started: October 4, 2021
First decision: December 12, 2021
Revised: January 8, 2022
Accepted: July 18, 2022
Article in press: July 18, 2022
Published online: August 19, 2022


Depression is a common problem in women in childbearing years due to burdens of motherhood and building a family. Few studies estimate the prevalence of antepartum depression compared to those in the postpartum period.


To estimate the prevalence and the severities of peripartum depression and major depressive disorder and their predictors.


This is a longitudinal observation study. It included 200 women scoring ≥ 13 with the Edinburgh Postpartum Depression Scale, indicating presence of symptoms of depression. They had a gestational age of ≥ 6 wk and did follow-ups until the 10th week to 12th weeks postpartum. Information of women's reactions to life circumstances and stressors during the current pregnancy were gathered from answers to questions of the designed unstructured clinical questionnaire. Severities of depression, anxiety, and parenting stress were determined by the Beck Depre-ssion Inventory, State-Trait Anxiety Inventory for Adults, and Parenting Stress Index-Short Form, respectively. Psychiatric interviewing was done to confirm the diagnosis of major depression. Measuring the levels of triiodothronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH) was done in both antepartum and postpartum periods.


Out of 968 (mean age = 27.35 ± 6.42 years), 20.66% (n = 200) of the patients had clinically significant symptoms of depression and 7.44% had major depression. Previous premenstrual dysphoria, post-abortive depression, and depression unrelated to pregnancy and were reported in 43%, 8%, and 4.5% of the patients, respectively. Psychosocial stressors were reported in 15.5% of the patients. Antepartum anxiety and parenting stress were reported in 90.5% and 65% of the patients, respectively. Postpartum T3, T4, and TSH levels did not significantly differ from reference values. Regression analysis showed that anxiety trait was a predictor for antepartum (standardized regression coefficients = 0.514, t = 8.507, P = 0.001) and postpartum (standardized regression coefficients = 0.573, t = 0.040, P = 0.041) depression. Antepartum depression (standardized regression coefficients = -0.086, t = -2.750, P = 0.007), and parenting stress (standardized regression coefficients = 0.080, t = 14.34, P = 0.0001) were also predictors for postpartum depression.


Results showed that 20.66% of the patients had clinically significant symptoms of depression and 7.44% had major depression. Anxiety was a predictor for antepartum and postpartum depression. Antepartum depression and parenting stress were also predictors for postpartum depression.

Key Words: Peripartum depression, Antepartum depression, Postpartum depression, Anxiety, Edinburgh postpartum depression scale, Parenting stress

Core Tip: The prevalence rates of depression and anxiety are higher in pregnant women compared to non-pregnant women because motherhood and family responsibilities represent additional burdens on pregnant woman. The prevalence rate of peripartum depression has been estimated to range from 5%-58% or even higher in different nations; however, meta-analyses studies from different countries and populations reported similar approximated prevalence rates for postpartum, as well as antepartum, depression, which is 10%-16.4%. A unified consensus has been made to use specific screening tools for determination of peripartum depression. The Edinburgh Postpartum Depression Scale is a commonly and widely used 10-item screening questionnaire with an estimated sensitivity of 75%-100% and a specificity of 76%-97%. Here, we estimated the prevalence of antepartum and postpartum depression for Egyptian women and determined their independent risk predictors.


Depression is common among adults[1,2]. The estimated prevalence of depression among Americans aged 20 and over in a given 2-wk period during the years 2013 to 2016 was 8.1%, with twice folds higher rates in women than men[2] . During the childbearing years, women are also more susceptible to major stresses, depression, and other psychiatric conditions and disorders due to superimposed children and family burdens[1]. There is a wide range of prevalence rates of antepartum and postpartum depression (i.e. peripartum depression) reported from different countries worldwide, with estimates ranging from 5% to 58% or even higher[3-7]. This is non-surprisingly attributed to different population characteristics, socioeconomic states, and time and methods for evaluation[8-12]. However, meta-analyses of large studies done in different areas of the world have shown that the approximate estimated prevalence is 10% to 15% for antepartum depression[13-17] and 10% to 16.4% for postpartum depression[18-20]. It has been indicated that the prevalence rates of postpartum depression seems closer or even similar to that of antepartum depression[21,22]. Studies have also shown the greater risk for being admitted to a psychiatric hospital is at the 1st month after delivery than at any time of life[3,8,13,18]. The American Psychiatric Association uses the term "peripartum depression" to define major depression in its diagnostic and statistical manual of mental disorders version 5 (DSM-5) to characterize depression which occurs in the antepartum (during pregnancy) and postpartum (within the first 4 wk after delivery) periods[23]. However, it has been recommended to expand the diagnostic criteria from 1 mo to 6 mo after delivery, as it has been observed that this entire period carries a high-risk for developing depression[24].

Despite the large amount of research over decades to determine the prevalence, risks, and causes of peripartum depression and find effective methods for its screening, prevention, and treatment, the risks and causes of peripartum depression are poorly understood. Several experimental and clinical research studies have suggested that the major risk for developing peripartum depression is the rapid fluctuation in reproductive hormones during pregnancy, delivery, and postpartum periods[25]. Others suggested "alternative biological processing" as the cause of peripartum depression which is based on the finding of different peripartum depression phenotypes that reflect complex mechanisms which include an interplay between: (1) Fluctuations in reproductive[25], thyroid[26], hypothalamic pituitary adrenal axis axis[27], and lactogenic hormones (prolactin and oxytocin)[28]; (2) Immunity[29]; (3) Genetics[30]; and (4) Social, obstetric, and psychological factors[3,8,13,18,31].

Peripartum depression is a major cause of maternal and neonatal morbidity if untreated[32]. Therefore, the World health Organization and United States Preventive Services Task Force recommend screening for peripartum depression. Interventions for mild/moderate symptoms include psychotherapy or treatment with antidepressants (e.g., selective serotonin reuptake inhibitors) and combined psychotherapy and pharmacotherapy for moderate/severe symptoms[33,34].

Studies which estimated the prevalence of antepartum depression are few compared to those in the postpartum period. Here, we aimed to estimate the prevalence of depression in women in the antepartum and postpartum periods and their demographic, social, obstetric, psychological, and hormonal predictors.

Study design, period, region

This is a longitudinal observational study completed over a period of 3 years (2017-2020). The initial sample size composed of 1100 women who were consequently recruited from the antenatal out-patient clinic of the department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt. Inclusion criteria were: (1) Gestational age of more than or equal 6 wk (i.e. antepartum period); (2) Compliance to the study's follow-up schedule during pregnancy (i.e. antepartum period) and at least 10 to 12 wk after delivery (i.e. postpartum period)[24]; (3) Matched social, economic, and educational levels; and (4) Edinburgh Postpartum Depression Scale (EPDS) screening questionnaire scoring of at least 13, indicating presence of clinically significant symptoms of depression[35,36]. Exclusion criteria was: Past history of significant medical or psychiatric diseases. The ethics Committees of Faculties of Medicine of Mansoura and Assiut Universities, Mansoura and Assiut Governorates, Egypt, approved the study protocol. Women gave their informed consents for participation in the study, No. AUFM_NP/OG_422/2016.


The social, economic and educational level evaluations: Evaluations for social, economic, and educa-tion levels were done using the Socio-Economic Scale[37], a structured questionnaire which collects information about level of parents' education, month's income, sanitation, and crowning index. Its total scoring is 30. The socioeconomic status is classified as high (scoring: more than 25 to at least 30), middle (scoring: more than 20 to at least 25), low (scoring: at least 15 to less than 20), or very low (scoring: less than 15).

Psychometric evaluations and testing: They were done by the specialist psychiatrist (ME).

In the Antepartum period (gestational age of more than or equal 6 wk)

EPDS: This is a widely used screening questionnaire for perinatal depression. It has ten questions which ask about the recent reaction (a week prior to its administration) of the woman to life stressors and conditions. EPDS scoring more than 13 indicates presence of symptoms of depression[35,36].

Clinical questionnaire: We designated an unstructured clinical questionnaire to collect information about the woman's reactions to recent life circumstances, events, and stresses related to the recent pregnancy. The questions asked about: (1) Feeling of happiness; (2) Husband's feeling towards his wife's recent pregnancy; (3) Reaction of the husband towards baby's sex; (4) History of child loss (abortions or stillbirths); (5) Postpartum complications; (6) Psychosocial stressors (e.g., divorce, loss of job, death of a husband, family arguments, and financial problems); (7) Husband's aggression against his wife (verbal, emotional, or physical); (8) Sexual abuse during childhood; (9) Previous psychiatric problems; and (10) Presence of family members with psychiatric problems.

DSM-5: Psychiatric interviewing was done for confirmation of the diagnosis of major depression according to the Structured Clinical Interview for DSM-5 (Structured clinical interview for DSM-5)[38].

Beck depression inventory II

The severity of symptoms of depression was determined using Beck depression inventory II (BDI-II)[39,40]. They were classified as minimal (scoring: 0-13), mild (scoring: 14-19), moderate (scoring: 20-28), or severe (scoring: 29-63).

State-Trait Anxiety Inventory for adults

The severity of manifestations of anxiety was determined using State-Trait Anxiety Inventory for adults (STAI-AD)[41,42]. STAI helps to differentiate between state from trait anxiety. State anxiety is a temporary condition while trait anxiety is long-lasting and more general condition. It also differentiates between subjective feelings of anxiety from depression. The severity of anxiety symptoms was classified as absent (scoring: less than or equal 20), mild (scoring: 21-30), less than moderate (scoring: 31-36), moderate (scoring: 47-42), more than moderate (scoring: 44-57), severe (scoring: 58-63), or very severe (scoring: more than or equal 64).

Antepartum laboratory testing

Antepartum laboratory testing was done at the early week of the third trimester. After an overnight fast (for 12 h), blood samples were withdrawn at 8:00 a.m. to measure serum levels of triiodothronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH) using immunoenzymetric assay kits [IMMULITE reproductive hormone assays' kits (Diagnostic products corporation, Los Angeles, United States)]. The reference levels are: T3 = 81-178 ng/dL, T4 = 4.5-12.5 ng/dL, and TSH = 0.4-4 mIU/mL.

In the postpartum period (at least 10 to 12 wk after delivery):

Participants were evaluated in the postpartum period using BDI-II[39,40].

Parenting Stress Index-Short Form[43]: The Parenting Stress Index-Short Form is 36-item questionnaire divided into three sets of questionnaires (or subscales of 12 items for each) to assess: (1) Parental Distress due to the parental role (e.g., the new responsibility being a mother makes me as being locked down); (2) Parent-Child Dysfunctional Interaction (e.g., this new child put on me a greater demand compared to my other kids); and (3) Difficult Child (e.g., This child does not provide me with empathy as I expect from a child to a mother). Each subscale's set has score ranging from 12-60. Parenting stress index-short form (PSI-SF) score is the sum of three subscales' set scores (range: 36-180). The higher scoring indicates enhanced stress level. A raw score exceeding 90 indicates significant symptomatic stress.

Postpartum laboratory testing: Measurement of the levels of T3, T4, and TSH were done in the 10th week postpartum.

Statistical analyses

Data were processed using SPSS for windows, version 20.0 (SPSS Inc., Chicago, IL, United States). Comparative statistics were carried out with t- and Chi-square tests or ANOVA (if variables are more than two). Correlation analyses between an antepartum score of BDI-II and the results of demographic, socio-economic status scoring, and psychometric testing's scores were carried out with Spearman's rho correlation coefficient. Multiple logistic regression analysis was carried out to check for demographic, clinical, and psychosocial factors, which independently predict or associate with antepartum and postpartum depression. Significance was considered with probability value less than 0.05.


The number of women screened for depression was 968; of them 200 (20.66%) had EPDS scoring more than 13 (i.e. had clinically significant symptoms of depression) (Figure 1A). The patients’ ages ranged from 17 years to 34 years (mean: 27.35 ± 6.42 years), with the majority having an age range between 23 years to 34 years (n = 164, 82%). All were housewives, the majority were rural residents (n = 155, 77.5%), cannot read (n = 145, 72.5%), and were of middle socioeconomic status (n = 132, 66%). Nearly half were multipara. A past history of fetal losses (abortions and still births) was found in 40%. The majority had normal vaginal deliveries in their past pregnancies, as well as the current pregnancy (n = 168, 84%). Only one patient underwent in vitro fertilization in the current pregnancy. The majority (n = 156, 78%) did their first visit to the antenatal care unit (parallel to our first psychiatric evaluation) in the 3rd trimester, with 13.5% (n = 27) in the 2nd and 8.5% (n = 17) in the 1st trimesters. Antenatal complications in the recent pregnancy which were indications for caesarian section were found in 16% (n = 32). Only 4% (n = 8) had postpartum problems (Table 1). Results of the unstructured clinical questionnaire showed that the majority of the patients (91%) were happy with their current pregnancy, and none had past history of postpartum depression; however, 43% had a history of premenstrual dysphoric disorder, 8% had history of post-abortive depression, and 4.5% had history of depression unrelated to pregnancies. Only one had history of sexual abuse during childhood. Psychosocial stressors were found in 15.5% (Table 2).

Figure 1
Figure 1 Antepartum depression. A: Prevalence rate of antepartum depression. B: Severities of antepartum depression.
Table 1 Demographic, social, and obstetric characteristics of screened women with symptoms of depression.
Demographic and social characteristics
n = 200
Age, yr17–34 (27.35 ± 6.42)
17-22 yr, n (%)36 (18)
23-34 yr, n (%)164 (82)
Urban40 (20)
Rural160 (80)
Maternal education
None (can't read)145 (72.5)
Can read (or can read and write)18 (9)
Primary6 (3)
Secondary12 (6)
High19 (9.5)
Socio-economic status
Low36 (18)
Middle132 (66)
High32 (16)
Obstetric characteristics
Primipara97 (48.5)
Multipara103 (51.5)
History of fetal loss
Abortions74 (37)
Still births6 (3)
Mode of previous deliveries
Vaginal168 (84)
Cesarean30 (15)
Both vaginal and cesarean2 (1)
History of in vitro fertilization in the current pregnancy1 (0.5)
Gestational age of the first antenatal care visit
First trimester17 (8.5)
Second trimester27 (13.5)
Third trimester156 (78)
Type of delivery in the current pregnancy
Vaginal168 (84)
CS32 (16)
Indications of CS (i.e. antenatal complications)32 (16)
Placenta previa22 (11)
Accidental hemorrhage8 (4)
Obstructed labor2 (1)
Postpartum complications of current pregnancy8 (4)
Table 2 Results of the women's reactions to the recent life circumstances, events, and stresses related to recent pregnancy.
Psychiatric characteristics
n = 200, n (%)
I was unhappy with the current pregnancy 10 (5)
My husband was unhappy with the current pregnancy0
Reaction to the current baby’s sex
Happy182 (91)
Indifference18 (9)
Past history of loss of a living child14 (7)
Past history of mental illness unrelated to pregnancy9 (4.5)
Depression and/or anxiety
Treated2 (1)
Untreated7 (3.5)
Past history of postpartum depression0
History of premenstrual dysphoric disorder86 (43)
Past history of post-abortive depression16 (8)
Past history of depression unrelated to pregnancies9 (4.5)
Family history of mental illness0
Past history of being a victim of one of the followings
Sexual abuse during childhood1 (0.5)
Physical abuse during childhood32 (16)
Physical abuse by a known person2 (1)
Physical abuse by an unknown person0
Physical aggression during pregnancy2 (1)
Emotional/verbal abuse22 (11)
Current psychosocial stressors31 (15.5)
Loss of a job0
Death of spouse1 (0.5)
Family argument24 (12)
Financial problems6 (3)

During pregnancy, symptoms of severe depression were found in 36% (mean Beck Depression Inventory II or BDI-II scoring: 44.48 ± 6.55), while 27% (mean BDI-II scoring: 24.26 ± 3.32) and 20.5% (mean BDI-II scoring: 16.26 ± 2.86) had moderate and mild symptoms, respectively (Figure 1 and Table 3). Psychiatric interviewing also showed that 7.44% (72/968) had major depression (women with severe symptoms). When stratified according to demographic, social, and obstetric variables, we observed no difference in severities of symptoms of depression in relation to age (P = 0.452), education levels (P = 0.326), or socioeconomic status (P = 0.482). When distributed according to the gestational age at presentation, the majority (n = 156, 78%) had symptoms of depression during the 3rd trimester, 13.5% (n = 27) during the 2nd, while only 8.5% (n = 17) had depression during the 1st trimester (P = 0.0001).

Table 3 Comparative statistical results of symptoms of depression during pregnancy according to social, demographic, and obstetric variable.
Socio-demographic and obstetric variablesThe severity of depression symptoms
P value
Minimal, n = 54, 27%
Mild, n = 41, 20.5%
Moderate, n = 33, 16.5%
Severe, n = 72, 36%
Age, n (%)0.452
17-22 yr (n = 36)7 (19.4)8 (22.2)9 (25)12 (33.3)
23-34 yr (n = 164)47 (28.7)33 (20.1)24 (14.6)60 (36.6)
Maternal education, n (%)0.326
Low (n = 181)29 (16)40 (22.1)44 (24.3)68 (37.6)
High (n =19)4 (10.5)1 (5.3)9 (47.4)5 (26.3)
Socio-economic status, n (%)0.482
Low (n = 36) 9 (25)5 (13.9)3 (8.3)19 (52.8)
Middle (n = 132)25 (18.9)33 (26.8)26 (19.7)48 (36.4)
High (n = 32)20 (62.5)3 (9.4)4 (12.5)5 (15.6)
Gestational age, n (%)0.0001
1st trimester (n = 17)2 (11.8)1 (5.9)5 (29.4)9 (52.9)
2nd trimester (n = 27)2 (7.4)5 (18.5)9 (33.3)11 (40.7)
3rd trimester (n = 156)50 (32.1)35 (22.4)19 (12.2)52 (33.3)

Compared to reference values, women in their 3rd trimester had higher levels of T3 and T4, but not TSH (Table 4). No difference in levels of T3, T4, and TSH in the postpartum period were detected compared to reference values.

Table 4 Hormonal results in the antepartum period.
Laboratory investigationsParticipants, n = 200
P value1
P value2
T3 in ng/dL, range 106–305 (184.22 ± 38.13)49.06–296 (164.70 ± 45.72)0.050.678
High, n (%)98 (49)80 (40)--
T4 in ng/dL, range 5.2–28 (12.40 ± 2.38)4.5–19.1 (11.19 ± 2.67)0.050.845
High, n (%)63 (31.5)82 (41)--
TSH in mIU/mL, range0.02–8.50 (1.70 ± 0.11)0.01–8.44 (1.64 ± 0.32)0.4350.760
High, n (%)5 (2.5)22 (11)--
Low, n (%)1 (0.5)---
Borderline, n (%)15 (7.5)---

The majority of women had symptoms of severe anxiety (n = 181, 90.5%) compared to less severe symptoms (P = 0.0001) [no anxiety = 1 (0.5%); mild = 6 (3%); less than moderate = 12 (6%); moderate = 8 (4%); more than moderate = 70 (35%); severe = 67 (33.5%); and very severe = 36 (18%)]. They had STAI-AD scoring ranged between 21 and 78 (mean: 53.31 ± 11.82) (Table 5).

Table 5 Comparative statistics between antepartum and postpartum manifestations of depression.
Psychiatric manifestationsParticipants, n = 200
P value
BDI-II score, range1–38 (26.13 ± 8.85)2–46 (22.27 ± 6.74)0.455
Severity of depression, n (%)0.0001
Minimal33 (16.5)104 (52)
Mild41 (20.5)64 (32)
Moderate54 (27)27 (13.5)
Severe72 (36)5 (2.5)
STAI score, range21–78 (53.31 ± 11.82)--
PSI-SF score, range-36–18 (136.57 ± 45.86)-
Women with clinically significant stress, n (%)-130 (65)-

Assessment of women in the postpartum period showed reduction in the severity of symptoms of depression (P = 0.0001). Approximately, two thirds (n = 130, 65%) had clinically significant parenting stress (Table 5).

Significant correlations were found between BDI-II scoring in the antepartum period and socioeconomic status scoring (r = -0.224, P = 0.001), STAI scoring (r = 0.600, P = 0.0001), and PSI-SF scoring (r = 0.141, 0.047), but not with age (r = -0.021; 0.763) and BDI-II scoring in the postpartum period (r = -0.110, P = 0.320). Significant correlation was found between BDI-II scoring in the postpartum period and PSI-SF scoring (r = 0.158, 0.052). Multiple regression analysis showed that in the antepartum period, only anxiety was the strong predictor of depression (standardized regression coefficients = 0.514, t = 8.507, P = 0.001). In the postpartum period, antepartum depression (standardized regression coefficients: -0.086, t: -2.750, P = 0.007), anxiety (standardized regression coefficients = 0.573, t = 0.040, P = 0.041), and parenting stress (standardized regression coefficients = 0.080, t = 14.34, P = 0.0001) were the predictors for postpartum depression (Table 6).

Table 6 Predictors for antepartum and postpartum depression in pregnant women.
Predictor variables
P value
Age -0.020-0.015-0.2870.774
Socio-economic scale -0.015-0.070-1.2860 .200
History of postpartum depression-0.834-0.083-1.6470.101
Antepartum anxiety trait0.4690.5148.5070.001
Antepartum T3 level-0.036-0.045-1.6730.513
Antepartum T4 level-0.046-0.056-1.8930.654
Antepartum TSH level-0.045-0.089-1.6540.607
Antepartum depression-0.0863-0.1483-2.75030.0073
Parenting stress index0.08030.697314.3430 .00013
R = 0.843; R = 0.8063
R2 = 0.711; R2 = 0.6493
Adjusted R2 = 0.701; Adjusted R2 = 0.6413
Standard error = 6.094; Standard error = 7.2543
ANOVA < 0.001; ANOVA < 0.0013

Results of this study showed that 20.66% of pregnant women had clinically significant symptoms of depression. Severe symptoms were found in 36% (72/200) of women, and this group also fulfilled the criteria of major depression, meaning that 7.44% (72/968) of women developed major depression in the peripartum period. Women included in this study had a closer age for marriage and similar obstetric characteristics as the rest of the world. The majority were from rural areas, had lower levels of education, and moderate/low socioeconomic statuses. There also shared psychological stressors regardless of culture. However, ours had distinguished characters and predictors; for example, more than 90% were happy with their current pregnancy, 4.5% had history of depression unrelated to pregnancies, 15.5% had psychosocial stressors, 78% developed manifestations of depression in the 3rd trimester, and 90% had manifestations of anxiety (which varied from moderate to very severe), but none fulfilled the diagnostic criteria of isolated generalized anxiety disorder and none had T3 and T4 (but not for TSH) levels out-ranged the reference values for non-pregnant women.

EPDS was the preferred screening tool for depression. In general, manifestations of peripartum depression are not specific. Therefore, a unified consensus has assigned 3 tools to screen women for peripartum depression[3-7], which are: (1) EPDS[35,36]: It is a 10-item questionnaire with an estimated sensitivity of 75% to 100% and a specificity of 76% to 97%; (2) Patient Health Questionnaire-9[44]: It has an estimated sensitivity of 75% and a specificity of 90%; and (3) The 35-question Postpartum Depression Screening Scale[45]: It has a sensitivity of 91% to 94% and a specificity of 72% to 98%. However, in practice, the family physicians usually use a familiar two-step screening questionnaire, Patient Health Questionnaire-2, as a first step, followed by comprehensive questionnaire if one from the two questions indicates presence of symptoms of depression.

Nationwide studies showed wide range prevalence rates for peripartum depression; however, a common prevalence estimate for antepartum depression nationwide is around 13%[20,21,46]. Our results showed a closer prevalence rate to those reported from different countries. In Egypt, few studies addressed the same topic (antepartum or postpartum depression) and its predictors[5,9,14]. Prevalence estimates from different countries are as follow: 14.8% in Spain[17], 16.8% in Turkey[47], 18% in Bangladesh[6], 24.3% in Oman[15], 27% in Canada[48], 32.9% in Cote d’Ivoire[7], 33.8% in Tanzania[49], and 44.2-57.5% in Saudi Arabia[16,50]. In Egypt, Abdelhai and Mosleh[9] did a cross sectional study on 376 randomly recruited pregnant women. The authors used a Hospital Anxiety and Depression Scale questionnaire and Hurt, Insulted, Threaten, and Scream Inventory (to screen for the presence of domestic violence). The authors found both depression and anxiety in 63% of the subjects and only anxiety in 11.4% or depression in 10.4% of the subjects. Domestic violence was found in 30.6% of the subjects, with the majority (25.2%) experienced physical violence from the husband. The authors found significant independent association between the presence of anxiety and depression and exposure to domestic violence (OR = 3.27, 95%CI: 1.28-8.34; P = 0.013), particularly among women who had husbands of low educational level compared to those with higher levels (i.e. a university-graduated) (OR = 0.22, 95%CI: 0.64-0.75, P = 0.01).

Previous studies found that there are several factors which could either associate or potentiate antepartum depression[51]. In this study, although women encountered significant psychosocial stresses, regression analysis showed that none was an independent predictor for peripartum depression. Also, none of the demographic, education, socioeconomic, or obstetric factors independently predicted peripartum depression. It is not surprising to find absence of an association between younger age of marriage and low levels of education or socioeconomic status and antepartum depression, particularly in Arab and some low/middle income countries, because, a female is protected by her family or husband’s family (i.e. each spouse's family will be responsible for the financial burden for pregnancy, delivery, and even earlier postnatal care). Oman Islam et al[52] found that neither the maternal age nor the gravidity was a risk for antepartum depression. In contrast, several studies found that the young age of marriage is a predictor for antepartum depression. They suggested that the financial hardship, unwanted pregnancies, and a lack of partner support are the main causes of depression among younger mothers[53,54]. Prost et al[55] found associations between stress and antepartum depression and older maternal age in Indian women. Some studies found correlations between peripartum depression and low levels of socioeconomic status and education[56,57]. In Brazilian women, Melo et al[57] found 2.38-fold increase in the odds of antepartum depression in association with low maternal educational level (OR = 2.38; 95%CI: 1.38-4.12). In Mexican women, Lara et al[56] found 5-fold increase in the odds of postpartum depression in association with low maternal education (OR = 5.61; 95%CI: 1.87-16.80).

In this study, when stratified according to gestational age, we observed that the majority (78%) developed depression in their 3rd trimester (P = 0.0001); however, gestational age was not a predictor for depression. Also, none of the obstetric risk factors was a predictor for antepartum depression which is in contrast to several studies[31,58]. Bunevicius et al[31] found higher prevalence of depression in the 1st trimester and the lowest in mid-pregnancy. They even found differences in predictors of antepartum depression when stratified according to gestational age. They found that unwanted and unplanned pregnancy and high neuroticism were the independent predictors in the 1st, 2nd, and 3rd trimesters, while low education and previous episodes of depression were the independent predictors in the 3rd trimester. They also observed that psychosocial stressors in the end of pregnancy were trimester specific.

In this study, psychosocial stressors (including previous depression episodes, family history of depression, premenstrual dysphoria, domestic violence, and sexual abuse) were found in 15.5%. Prost et al[55] screened 5801 Indian mothers from rural Jharkhand and Orissa, eastern India, where over 40% of the population live below the poverty line, at 6 wk after delivery. The authors used the Kessler-10 item scale and found that 11.5% (95%CI: 10.7–12.3) had symptoms of distress (K10 score: more than 15). They found that the independent predictors for postpartum distress were high maternal age, severe poverty, health problems in the antepartum period, caesarean section, unwanted pregnancy from the mother's side, small infant size, and child loss (e.g., stillbirths or neonatal death). They also found that the loss of an infant (OR = 7.06, 95%CI: 5.51–9.04) or an unwanted pregnancy (OR = 1.49, 95%CI: 1.12–1.97) significantly increased the risk of maternal distress.

In this study, 90.5% of women had symptoms of moderate/severe anxiety in the antepartum period. In Sao Paulo, Brazil, Faisal-Cury and Rossi Menezes[59] found symptoms of depression of different severities in 20% of pregnant women assessed by BDI and nearly 60% had anxiety assessed by STAI. Karmaliani et al[60] found manifestations of anxiety and depression in 18% Pakistani pregnant women.

In this study, although major depressive disorder was diagnosed in 7.44% of pregnant women, neither antepartum nor postpartum bipolar disorder or history of bipolar disorder in the non-pregnancy periods was observed in the 968 women screened for this study. This could be attributed to the fact that this is not a population-based study. It is also possible that the prevalence rate for peripartum bipolar disorder is lower than unipolar or bipolar depression[61-63]. There are many published studies on both unipolar and bipolar postpartum depression, whereas there are few on bipolar postpartum depression. A survey on general population of the United States estimated that a 12 mo prevalence rate for postpartum bipolar disorder was 2.9%[61]. Authors also found that many women with postpartum bipolar disorder had acute mood episodes and the risk of bipolar episodes were greater during the postpartum period than other periods of life[62]. Wisner et al[63] found that among the 14% of women with postpartum depression, 22.6% actually had bipolar disorder.

In this study, the only predictor for antepartum depression was antepartum anxiety trait (P = 0.001). The predictors for postpartum depression were antepartum depression (P = 0.007), anxiety trait (P = 0.041), and parenting stress (P = 0.0001). Despite the observed reduction in the severity of symptoms of depression in the postpartum period (2.5%) compared to the antepartum period (36%), antepartum depression was also a strong predictor for postpartum depression (P = 0.007). Previous studies indicated that antepartum anxiety is an independent predictor for both antepartum and postpartum depression[64], and severe anxiety and even panic attacks are often associated with peripartum major depressive episode[65]. Faisal-Cury and Rossi Menezes[59] screened 432 women from Osasco, São Paulo, for depression and anxiety using STAI and BDI designed questionnaires. The authors found a prevalence of 59.5% for anxiety state (95%CI: 54.8-64.1), 45.3% for anxiety trait (95%CI: 40.6-50.0), and 19.6% for depression (95%CI: 15.9-23.4). The authors found that the mothers' low levels of education and the absence of formal marriage were significant independent predictors for anxiety trait (OR = 5.26; 95%CI: 2.17-12.5, P = 0.001; OR = 3.43; 95%CI: 1.68-7.00, P = 0.001), anxiety state (OR = 2.27; 95%CI: 1.08-4.76, P = 0.02; OR = 2.22; 95%CI: 1.09-4.53, P = 0.02), and depression (OR = 2.43; 95%CI: 1.40-4.34, P = 0.002; OR = 2.82; 95%CI: 1.35-5.97, P = 0.005). They found that women with lower incomes (OR = 2.22; 95%CI: 0.98-5.26, P = 0.05) and a race other than white (OR = 1.7; 95%CI: 1.00-2.91, P = 0.04) were significant independent predictors for anxiety trait. They also found that couples with lower income (OR = 2.43; 95%CI: 1.40-4.34, P = 0.001) and frequent previous abortions (OR = 2.21; 95%CI: 1.23-3.97, P = 0.009) were significant independent predictors for depression. In the two different community studies done by Karaçam and Ançel[65] on 1039 Turkish pregnant women, the authors found manifestations of severe depression in 27.9% which required antidepressants therapy. The authors found that the lack of social support, recent life stresses, or domestic violence just before or during the recent pregnancy, and negative self-perception were strong independent predictors for both depression and anxiety; and formal marriage and its dissatisfaction, unwanted pregnancy, and being a housewife were strong independent predictors for depression only.

In this study, we found that the only predictors for postpartum depression were antepartum depression, anxiety, and parenting stress. Studies from the developed and developing areas of the world indicated a strong association between postpartum and antepartum depression. Some even found that the only predictor for postpartum depression was antepartum depression[64-66] Several studies also found that antepartum anxiety is associated (10%-29%) and a strong predictor for postpartum depression[66]. In the recent study done by Abd Elaziz and Abdel Halim[19] on 120 Egyptian women, the authors found postpartum depression in 27.5% of the subjects. They found that the predictors for postpartum depression were the presence of domestic violence (OR = 6.4, 95%CI: 2.5-15.3), previous episodes of postpartum depression (OR = 5.5, 95%CI: 1.6-17.9), presence of stressful life events (OR = 3.6, 95%CI: 1.4-8.1), and difficult social interaction at the time of stress (OR = 4.1, 95%CI: 1.7-9.1). Previous studies reported an association between postpartum depression and parenting stress. Leigh and Milgrom[46] screened women from Angliss and Northern Victorian hospitals and found higher PSI scores in women with postpartum depression compared to non-depressed women (P < 001). They found significant independent associations between postpartum depression and parenting stress (P < 0.001) and previous history of depression (P < 0.01). It has been suggested that in addition to parenthood, more burden is added on a working or career-oriented mother as being unable to carry out many work authorizations and home responsibilities.

In this study, we did not identify a significant correlation between thyroid hormonal changes in the peripartum period and depression. The role of hormonal fluctuations during perinatal period and its relationship to peripartum depression is not established. and many studies have controversial results[28,67-70]. For example, Amino et al[69] found low mean values of T4 levels during the 3rd trimester and early postpartum periods in women with postpartum depression. Abou-Saleh et al[70] found significant increase in levels of postpartum T4 in women with depression compared to unmarried/non-pregnant women; higher T4 was the only predictor for severe antepartum depression, and higher TSH was found in women with high scoring of EPDS, indicating presence of clinically significant symptoms of depression, and had previous history of depression compared to those without past history of depression. In the systematic review done by Szpunar and Parry[28] which included studies on women in the peripartum period who had major depression and did repeated measurements of TSH levels in the antepartum or postpartum periods, the authors found controversy between the studies and an absence of association between TSH and peripartum depression.

We suggest the followings as causes of differences between the results of this study and others: (1) Differences in methodologies (laboratory, screening questionnaires, and psychometric testing evaluation in different trimesters and postpartum periods) or study settings (e.g., community or hospital-based or recruitment from primary health care center); (2) The causes and risks for peripartum depression could not be primarily or solely attributed to the biological changes during this stressful period of life; and (3) Differences in culture, beliefs, and genetic vulnerabilities: We suggest that that the observed high frequency of antepartum anxiety and its relationship to depression could be attributed to poverty, illiteracy, lack of social support, domestic violence, and psychological stressors.


There is wide variation in prevalence rates of peripartum depression from different countries. Our results showed that 20.66% had clinically significant symptoms of depression and 7.44% had the diagnosis of major depression. Although the topic has already been addressed in other studies and the results of the study corroborate the data found in the literature with regards the prevalence, predictors, and severity of depressive symptoms, the results of this study may help improve knowledge, taking into account the prevalence of the disease which is not always recognized and valued. Antepartum anxiety was the only variable found as a predictor for antepartum depression and also for postpartum depression, together with antepartum depression and parenting stress. Therefore, screening for peripartum depression and its risks is important.

Research background

Depression is a common public health problem. It is an important cause of morbidity for mothers in their peripartum period, with an estimated prevalence of 7%-58% or even higher in some countries. A common prevalence of antepartum or postpartum depression reported in different studies is approximately 13%. The suggested mechanism(s) of peripartum depression include(s) complex interplay between biological factors (fluctuation in reproductive, thyroid, and hypothalamic pituitary adrenal axis hormones), immune system activity, genetics, and psychosocial stressors. Therefore, World health Organization and United States Preventive Services Task Force recommend screening for women in peripartum period looking for manifestations of depression and determine their risks.

Research motivation

The research hotspots include determination of: (1) The prevalence of peripartum (antepartum and postpartum) depression. Because related studies are few for antepartum compared to postpartum depression; (2) The severities of depression in relation to different demographic, social, obstetric, hormonal, and psychological variables; and (3) The predictors which are independently associated with each of antepartum or postpartum depression.

Research objectives

This study systematically assessed women in their peripartum period to estimate the prevalence and predictors of peripartum depression.

Research methods

The Edinburgh Postpartum Depression Scale screening questionnaire; designed unstructured clinical questionnaire to gather information about the women's reactions to recent life circumstances, events, and stress in relation to the recent pregnancy; Beck Depression Inventory II, the State-Trait Anxiety Inventory for Adults, and Parenting Stress Index-Short Form for severity categorization of depression, anxiety, and parenting stress respectively; psychiatric interviewing to confirm the diagnosis of major depressive disorder (according to the Diagnostic and Statistical Manual of Mental Disorders, version 5); and measurements of triiodothronine, thyroxine, and thyroid stimulating hormone levels in the antepartum and postpartum periods.

Research results

The prevalence of women with clinically significant symptoms of peripartum depression in our locality is 20.66%. Major depression was found in 7.44%. Symptoms of depression were less severe in postpartum period than antepartum. Antepartum anxiety was the only predictor for both antepartum and postpartum depression. Antepartum anxiety and depression and parenting stress were the predictors for postpartum depression.

Research conclusions

Nearly one fifth of women developed clinically significant manifestations of depression in their peripartum period, mainly attributed to anxiety and parenting stress.

Research perspectives

In our locality, the importance of antepartum depression as a risk for postpartum depression and subsequently parenting stress has been largely under-recognized. Health care providers and insurance policies need to focus attention to the magnitude of the problem of peripartum depression to encourage education for obstetricians, mothers, and families about its high prevalence and associated risks. A multidisciplinary team for screening and management of peripartum depression is required (e.g., prevention and expertise guidance related to the recommended treatment options, such as psychotherapy and/or pharmacotherapy).


Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Psychiatry

Country/Territory of origin: Egypt

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): B, B

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): E

P-Reviewer: Ben Thabet J, Tunisia; Ching SM, Malaysia; Mendes R, Portugal S-Editor: Fan JR L-Editor: Filipodia P-Editor: Fan JR

1.  Blanco C, Okuda M, Markowitz JC, Liu SM, Grant BF, Hasin DS. The epidemiology of chronic major depressive disorder and dysthymic disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2010;71:1645-1656.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 78]  [Cited by in F6Publishing: 72]  [Article Influence: 6.0]  [Reference Citation Analysis (0)]
2.  Brody DJ, Pratt LA, Hughes J.   Prevalence of depression among adults aged 20 and over: United States, 2013–2016. NCHS Data Brief, no 303. Hyattsville, MD: National Center for Health Statistics. 2018.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106:1071-1083.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2030]  [Cited by in F6Publishing: 2179]  [Article Influence: 119.4]  [Reference Citation Analysis (0)]
4.  Husain N, Parveen A, Husain M, Saeed Q, Jafri F, Rahman R, Tomenson B, Chaudhry IB. Prevalence and psychosocial correlates of perinatal depression: a cohort study from urban Pakistan. Arch Womens Ment Health. 2011;14:395-403.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 43]  [Cited by in F6Publishing: 47]  [Article Influence: 3.6]  [Reference Citation Analysis (0)]
5.  Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery. 2011;27:e238-e245.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 127]  [Cited by in F6Publishing: 115]  [Article Influence: 9.8]  [Reference Citation Analysis (0)]
6.  Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Prevalence and associated factors of depressive and anxiety symptoms during pregnancy: a population based study in rural Bangladesh. BMC Womens Health. 2011;11:22.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 128]  [Cited by in F6Publishing: 150]  [Article Influence: 10.7]  [Reference Citation Analysis (0)]
7.  Bindt C, Appiah-Poku J, Te Bonle M, Schoppen S, Feldt T, Barkmann C, Koffi M, Baum J, Nguah SB, Tagbor H, Guo N, N'Goran E, Ehrhardt S; International CDS Study Group. Antepartum depression and anxiety associated with disability in African women: cross-sectional results from the CDS study in Ghana and Côte d'Ivoire. PLoS One. 2012;7:e48396.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 52]  [Cited by in F6Publishing: 56]  [Article Influence: 4.7]  [Reference Citation Analysis (0)]
8.  Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, Holmes W. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012;90:139G-149G.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 888]  [Cited by in F6Publishing: 991]  [Article Influence: 74.0]  [Reference Citation Analysis (0)]
9.  Abdelhai R, Mosleh H. Screening for antepartum anxiety and depression and their association with domestic violence among Egyptian pregnant women. J Egypt Public Health Assoc. 2015;90:101-108.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 20]  [Article Influence: 3.2]  [Reference Citation Analysis (0)]
10.  Saleh el-S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat. 2013;9:15-24.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 29]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
11.  Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health. 2014;128:817-824.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 22]  [Article Influence: 2.2]  [Reference Citation Analysis (0)]
12.  Yonkers KA, Ramin SM, Rush AJ, Navarrete CA, Carmody T, March D, Heartwell SF, Leveno KJ. Onset and persistence of postpartum depression in an inner-city maternal health clinic system. Am J Psychiatry. 2001;158:1856-1863.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 245]  [Cited by in F6Publishing: 257]  [Article Influence: 11.1]  [Reference Citation Analysis (0)]
13.  Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AM. Postpartum depression: prevalence and predictors among women at El Eman’s specialized hospital. J Am Sci. 2015;7:122-128.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 29]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
14.  Mohamed NR, Ragab AZ, Zeina MA. Psychiatric disorders in the postpartum period. Menoufia Medical J. 2015;28:565-570.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
15.  Al-Azri M, Al-Lawati I, Al-Kamyani R, Al-Kiyumi M, Al-Rawahi A, Davidson R, Al-Maniri A. Prevalence and Risk Factors of Antenatal Depression among Omani Women in a Primary Care Setting: Cross-sectional study. Sultan Qaboos Univ Med J. 2016;16:e35-e41.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 24]  [Article Influence: 2.7]  [Reference Citation Analysis (0)]
16.  Bawahab JA, Alahmadi JR, Ibrahim AM. Prevalence and determinants of antenatal depression among women attending primary health care centers in Western Saudi Arabia. Saudi Med J. 2017;38:1237-1242.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 10]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
17.  de la Fe Rodríguez-Muñoz M, Le HN, de la Cruz IV, Crespo MEO, Méndez NI. Feasibility of screening and prevalence of prenatal depression in an obstetric setting in Spain. Eur J Obstet Gynecol Reprod Biol. 2017;215:101-105.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 20]  [Article Influence: 3.2]  [Reference Citation Analysis (0)]
18.  Salem MN, Thabet MN, Fouly H, Abbas AM. Factors affecting the occurrence of postpartum depression among puerperal women in Sohag city, Egypt. Proc Obstet Gynecol. 2017;7:4.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
19.  Abd Elaziz SY, Abdel Halim HW. Risk factors for postpartum depression among Egyptian women. Al-Azhar Inter Med J. 2020;1:154-161.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
20.  Pearson RM, Carnegie RE, Cree C, Rollings C, Rena-Jones L, Evans J, Stein A, Tilling K, Lewcock M, Lawlor DA. Prevalence of Prenatal Depression Symptoms Among 2 Generations of Pregnant Mothers: The Avon Longitudinal Study of Parents and Children. JAMA Netw Open. 2018;1:e180725.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 58]  [Cited by in F6Publishing: 53]  [Article Influence: 11.6]  [Reference Citation Analysis (0)]
21.  Siu AL; US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, García FA, Gillman M, Herzstein J, Kemper AR, Krist AH, Kurth AE, Owens DK, Phillips WR, Phipps MG, Pignone MP. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315:380-387.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 864]  [Cited by in F6Publishing: 848]  [Article Influence: 123.4]  [Reference Citation Analysis (0)]
22.  Sadock BJ, Sadock VA, Ruiz P.   Distruptive mood dysregualation. In: Kaplan and Sadock’s comprehensive textbook of psychiatry (10th edition). Philadelphia: Loppincott Williams & Wilkins, 2017.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  American Psychiatric Association  Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Fifth edition. Arlington, VA. 2013..  [PubMed]  [DOI]  [Cited in This Article: ]
24.  O'Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol. 2013;9:379-407.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 885]  [Cited by in F6Publishing: 917]  [Article Influence: 88.5]  [Reference Citation Analysis (0)]
25.  Ahokas A, Kaukoranta J, Wahlbeck K, Aito M. Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17beta-estradiol: a preliminary study. J Clin Psychiatry. 2001;62:332-336.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 184]  [Cited by in F6Publishing: 188]  [Article Influence: 8.4]  [Reference Citation Analysis (0)]
26.  Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, Nixon A, Pearce EN, Soldin OP, Sullivan S, Wiersinga W; American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011;21:1081-1125.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1083]  [Cited by in F6Publishing: 1218]  [Article Influence: 90.3]  [Reference Citation Analysis (0)]
27.  Kammerer M, Taylor A, Glover V. The HPA axis and perinatal depression: a hypothesis. Arch Womens Ment Health. 2006;9:187-196.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 120]  [Cited by in F6Publishing: 125]  [Article Influence: 7.1]  [Reference Citation Analysis (0)]
28.  Szpunar MJ, Parry BL. A systematic review of cortisol, thyroid-stimulating hormone, and prolactin in peripartum women with major depression. Arch Womens Ment Health. 2018;21:149-161.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 26]  [Article Influence: 3.2]  [Reference Citation Analysis (0)]
29.  Butts CL, Sternberg EM. Neuroendocrine factors alter host defense by modulating immune function. Cell Immunol. 2008;252:7-15.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 75]  [Cited by in F6Publishing: 69]  [Article Influence: 5.0]  [Reference Citation Analysis (0)]
30.  Treloar SA, Martin NG, Bucholz KK, Madden PA, Heath AC. Genetic influences on post-natal depressive symptoms: findings from an Australian twin sample. Psychol Med. 1999;29:645-654.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 66]  [Cited by in F6Publishing: 70]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
31.  Bunevicius R, Kusminskas L, Bunevicius A, Nadisauskiene RJ, Jureniene K, Pop VJ. Psychosocial risk factors for depression during pregnancy. Acta Obstet Gynecol Scand. 2009;88:599-605.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 105]  [Cited by in F6Publishing: 92]  [Article Influence: 7.5]  [Reference Citation Analysis (0)]
32.  Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission. Psychol Rev. 1999;106:458-490.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1460]  [Cited by in F6Publishing: 1544]  [Article Influence: 60.8]  [Reference Citation Analysis (0)]
33.  Who interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis. Bull World Health Organ. 2013;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 224]  [Cited by in F6Publishing: 234]  [Article Influence: 22.4]  [Reference Citation Analysis (0)]
34.  O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;315:388-406.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 313]  [Cited by in F6Publishing: 313]  [Article Influence: 44.7]  [Reference Citation Analysis (0)]
35.  Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8260]  [Cited by in F6Publishing: 8521]  [Article Influence: 229.4]  [Reference Citation Analysis (0)]
36.  Ghubash R, Abou-Saleh MT, Daradkeh TK. The validity of the Arabic Edinburgh Postnatal Depression Scale. Soc Psychiatry Psychiatr Epidemiol. 1997;32:474-476.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 65]  [Cited by in F6Publishing: 69]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
37.  El-Gilany A, El-Wehady A, El-Wasify M. Updating and validation of the socioeconomic status scale for health research in Egypt. East Mediterr Health J. 2012;18:962-968.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 87]  [Cited by in F6Publishing: 88]  [Article Influence: 7.9]  [Reference Citation Analysis (0)]
38.  American psychiatry association (APA)  Structured clinical interview for DSM-5 (SCID-5). [cited 10 September 2021]. Available from: https://appi.org/.  [PubMed]  [DOI]  [Cited in This Article: ]
39.  Beck AT, Steer RA, Ball R, Ranieri W. Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. J Pers Assess. 1996;67:588-597.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3738]  [Cited by in F6Publishing: 3910]  [Article Influence: 138.4]  [Reference Citation Analysis (0)]
40.  Gharyb AG  Beck Depression Inventory II (BDI-II): Arabic examiner’s handbook. Cairo: Dar El-Anglo, 2000.  [PubMed]  [DOI]  [Cited in This Article: ]
41.  Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA.   Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press, Palo Alto: 1983.  [PubMed]  [DOI]  [Cited in This Article: ]
42.  Abdel-Khalek AM. The developmental and validation of an Arabic form of the STAI: Egyptian results. Pers Individ Dif. 1989;10:277-285.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 42]  [Cited by in F6Publishing: 42]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
43.  Abidin RR  Parenting Stress Index. Professional Manual. 3rd edition. Odessa, FL: Psychological Assessment Resources, Inc; 1995..  [PubMed]  [DOI]  [Cited in This Article: ]
44.  Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 21545]  [Cited by in F6Publishing: 22235]  [Article Influence: 979.3]  [Reference Citation Analysis (0)]
45.  Kabir K, Sheeder J, Kelly LS. Identifying postpartum depression: are 3 questions as good as 10? Pediatrics. 2008;122:e696-e702.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 49]  [Cited by in F6Publishing: 53]  [Article Influence: 3.3]  [Reference Citation Analysis (0)]
46.  Leigh B, Milgrom J. Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry. 2008;8:24.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 502]  [Cited by in F6Publishing: 536]  [Article Influence: 33.5]  [Reference Citation Analysis (0)]
47.  Akçalı Aslan P, Aydın N, Yazıcı E, Aksoy AN, Kirkan TS, Daloglu GA. Prevalence of depressive disorders and related factors in women in the first trimester of their pregnancies in Erzurum, Turkey. Int J Soc Psychiatry. 2014;60:809-817.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 14]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
48.  Bowen A, Muhajarine N. Prevalence of antenatal depression in women enrolled in an outreach program in Canada. J Obstet Gynecol Neonatal Nurs. 2006;35:491-498.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 62]  [Cited by in F6Publishing: 67]  [Article Influence: 3.6]  [Reference Citation Analysis (0)]
49.  Rwakarema M, Premji SS, Nyanza EC, Riziki P, Palacios-Derflingher L. Antenatal depression is associated with pregnancy-related anxiety, partner relations, and wealth in women in Northern Tanzania: a cross-sectional study. BMC Womens Health. 2015;15:68.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 48]  [Cited by in F6Publishing: 58]  [Article Influence: 6.0]  [Reference Citation Analysis (0)]
50.  Moawed SA, Gemaey EM, Al-Mutairi HA. Prevalence of Depression among Saudi Pregnant Women. IOSR-JNHS. 2015;4:61-68.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 3]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
51.  Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol. 2010;202:5-14.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 695]  [Cited by in F6Publishing: 775]  [Article Influence: 53.5]  [Reference Citation Analysis (0)]
52.  Islam MM, Dorvlo AS, Al-Qasmi AM. The pattern of female nuptiality in oman. Sultan Qaboos Univ Med J. 2013;13:32-42.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 14]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
53.  O'Hara MW, Schlechte JA, Lewis DA, Wright EJ. Prospective study of postpartum blues. Biologic and psychosocial factors. Arch Gen Psychiatry. 1991;48:801-806.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 237]  [Cited by in F6Publishing: 244]  [Article Influence: 7.4]  [Reference Citation Analysis (0)]
54.  Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ, Joffe H, Gillman MW. Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Community Health. 2006;60:221-227.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 401]  [Cited by in F6Publishing: 420]  [Article Influence: 23.6]  [Reference Citation Analysis (0)]
55.  Prost A, Lakshminarayana R, Nair N, Tripathy P, Copas A, Mahapatra R, Rath S, Gope RK, Bajpai A, Patel V, Costello A. Predictors of maternal psychological distress in rural India: a cross-sectional community-based study. J Affect Disord. 2012;138:277-286.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 30]  [Article Influence: 2.7]  [Reference Citation Analysis (0)]
56.  Lara MA, Berenzon S, Juárez García F, Medina-Mora ME, Natera Rey G, Villatoro Velázquez JA, Gutiérrez López Mdel L. Population study of depressive symptoms and risk factors in pregnant and parenting Mexican adolescents. Rev Panam Salud Publica. 2012;31:102-108.  [PubMed]  [DOI]  [Cited in This Article: ]
57.  Melo EF Jr, Cecatti JG, Pacagnella RC, Leite DF, Vulcani DE, Makuch MY. The prevalence of perinatal depression and its associated factors in two different settings in Brazil. J Affect Disord. 2012;136:1204-1208.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 53]  [Cited by in F6Publishing: 54]  [Article Influence: 4.8]  [Reference Citation Analysis (0)]
58.  Marcinko VM, Marcinko D, Dordević V, Oresković S. Anxiety and depression in pregnant women with previous history of spontaneous abortion. Coll Antropol. 2011;35 Suppl 1:225-228.  [PubMed]  [DOI]  [Cited in This Article: ]
59.  Faisal-Cury A, Rossi Menezes P. Prevalence of anxiety and depression during pregnancy in a private setting sample. Arch Womens Ment Health. 2007;10:25-32.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 177]  [Cited by in F6Publishing: 187]  [Article Influence: 11.1]  [Reference Citation Analysis (0)]
60.  Karmaliani R, Asad N, Bann CM, Moss N, Mcclure EM, Pasha O, Wright LL, Goldenberg RL. Prevalence of anxiety, depression and associated factors among pregnant women of Hyderabad, Pakistan. Int J Soc Psychiatry. 2009;55:414-424.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 92]  [Cited by in F6Publishing: 103]  [Article Influence: 6.6]  [Reference Citation Analysis (0)]
61.  Vesga-López O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65:805-815.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 627]  [Cited by in F6Publishing: 710]  [Article Influence: 41.8]  [Reference Citation Analysis (0)]
62.  Viguera AC, Tondo L, Koukopoulos AE, Reginaldi D, Lepri B, Baldessarini RJ. Episodes of mood disorders in 2,252 pregnancies and postpartum periods. Am J Psychiatry. 2011;168:1179-1185.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 176]  [Cited by in F6Publishing: 183]  [Article Influence: 14.7]  [Reference Citation Analysis (0)]
63.  Wisner KL, Moses-Kolko EL, Sit DK. Postpartum depression: a disorder in search of a definition. Arch Womens Ment Health. 2010;13:37-40.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 82]  [Cited by in F6Publishing: 84]  [Article Influence: 6.3]  [Reference Citation Analysis (0)]
64.  Kirpinar I, Gözüm S, Pasinlioğlu T. Prospective study of postpartum depression in eastern Turkey prevalence, socio-demographic and obstetric correlates, prenatal anxiety and early awareness. J Clin Nurs. 2010;19:422-431.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 39]  [Cited by in F6Publishing: 41]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
65.  Karaçam Z, Ançel G. Depression, anxiety and influencing factors in pregnancy: a study in a Turkish population. Midwifery. 2009;25:344-356.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 78]  [Cited by in F6Publishing: 66]  [Article Influence: 4.9]  [Reference Citation Analysis (0)]
66.  Beck CT. Predictors of postpartum depression: an update. Nurs Res. 2001;50:275-285.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1231]  [Cited by in F6Publishing: 1274]  [Article Influence: 56.0]  [Reference Citation Analysis (0)]
67.  Lucas A, Pizarro E, Granada ML, Salinas I, Sanmartí A. Postpartum thyroid dysfunction and postpartum depression: are they two linked disorders? Clin Endocrinol (Oxf). 2001;55:809-814.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 47]  [Cited by in F6Publishing: 46]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
68.  Keshavarzi F, Yazdchi K, Rahimi M, Rezaei M, Farnia V, Davarinejad O, Abdoli N, Jalili M. Post partum depression and thyroid function. Iran J Psychiatry. 2011;6:117-120.  [PubMed]  [DOI]  [Cited in This Article: ]
69.  Amino N, Tada H, Hidaka Y. The spectrum of postpartum thyroid dysfunction: diagnosis, management, and long-term prognosis. Endocr Pract. 1996;2:406-410.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 21]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
70.  Abou-Saleh MT, Ghubash R, Karim L, Krymski M, Bhai I. Hormonal aspects of postpartum depression. Psychoneuroendocrinology. 1998;23:465-475.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 116]  [Cited by in F6Publishing: 116]  [Article Influence: 4.6]  [Reference Citation Analysis (0)]