Depression in mothers during and after pregnancy increased the odds of depression in offspring during adolescence and adulthood by 70%, according to a new study by researchers at The University of Texas Health Science Center at Houston (UTHealth).
The systematic review was recently published in JAMA Network Open. It is the first study to examine the effects of maternal depression on children age 12 and older.
The authors note that 10-20% of mothers experience perinatal depression, which refers to the time during pregnancy (antenatal) or within the first year after birth (postnatal).
Perinatal depression has been associated with reduced growth rates, malnutrition, and an increased risk of childhood health problems and obesity.
“There are a lot of studies that look at how perinatal depression affects a child’s growth or emotional well-being, but we wanted to look at how it affects offspring later in life,” said Vaishali Tirumalaraju, MBBS, a resident with the Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School at UTHealth and one of the study’s first authors.
Researchers examined all published studies on the topic, zeroing in on six major cohorts following long-term symptoms in more than 15,000 children age 12 or older.
“We found that the offspring of mothers who had perinatal depression, especially antenatal depression, had a greater chance of having depression when they grow up,” said Sudhakar Selvaraj, MD, Ph.D., an assistant professor of psychiatry with McGovern Medical School, the director of the Depression Research Program, and the study’s senior author.
“This is important because it shows perinatal depression not only negatively affects the mother, but also has a lasting negative impact on the child.”
This research comes during a time of increased stress and strain on mental health, as the COVID-19 pandemic poses challenges for new and expecting mothers.
“Pregnancies during these times are particularly stressful given the social situation and physical distancing guidelines in place.
There are a lot of moms without support who have to isolate, and many are handling extra stressors with limited resources,” Tirumalaraju said.
“Stress can cause changes in eating habits, less desire to exercise, and overall less healthy behaviors that can lead to depression,” said Selvaraj, a psychiatrist with UT Physicians, the clinical practice of McGovern Medical School.
“Due to stigma, depression is hard to track because often mothers don’t want to report that they are sad or having trouble mentally. Our study shows the potential long-term impact of depression in offspring and therefore the need for proper screening so that moms who could benefit from counseling and/or medication can be provided the resources they need.”
Selvaraj is part of the UTHealth Women’s Mental Health Program, which provides access to specialists in psychology and psychiatry in certain UT Physicians Women’s Centers, simplifying the process for women to seek help for perinatal depression and other mental health conditions.
Study authors say more research into the factors involved in depression risk transmission and assessments of how to reduce this risk could help develop future strategies to mitigate depressive disorders in pregnancy.
Increasing evidence suggests that psychosis is best viewed as a continuum and that psychotic experiences not meeting criteria for psychotic disorder are much more common in both the adolescent and adult populations than previously realised.1
Psychotic experiences could represent the milder end of the psychosis continuum. Children and adults who report psychotic experiences during childhood are at higher risk of developing a psychotic disorder such as schizophrenia during adulthood.1
There is also evidence that psychotic experiences are not just related to psychotic disorders but are also associated with more severe presentations of common mental health disorders such as anxiety and depression.2
Thus, the study of psychotic experiences is relevant to both the early phases of development of psychotic disorders1 and the more severe presentations of common mental health disorders.
Maternal perinatal depression is known to have an adverse effect on several aspects of child development, including social, emotional, and cognitive function,3, 4 and is associated with offspring depressive symptoms in adolescence5 and adulthood.6
The neurodevelopmental hypothesis of schizophrenia proposes that abnormal brain development might contribute to the development of the disorder.7 Maternal perinatal depression is a form of psychological distress and might reflect chronic maternal stress, which could affect neurodevelopment of offspring,3 increasing offspring risk of psychotic experiences.
Antenatal depression might affect fetal neurodevelopment in utero and have epigenetic effects on the fetus.3 In addition, antenatal depression might have effects on postnatal bonding and parenting.
Maternal postnatal depression might negatively affect bonding and parenting during infancy, which might affect offspring attachment style4 and increase the risk of psychotic experiences.8
If a causal association were to be found between maternal perinatal depression and offspring psychotic experiences, there is the potential for intervention during this crucial period to reduce not only maternal distress but also offspring risk in the future.
To our knowledge, this study is the first to examine the association between maternal depressive symptoms during the perinatal period and offspring psychotic experiences at 18 years of age.
We found evidence that the offspring of mothers with higher perinatal depressive symptom scores were more likely to report psychotic experiences than the offspring of mothers with lower depressive scores.
This finding is consistent with the hypothesis that maternal depression during the perinatal period might be a risk factor for offspring psychotic experiences. The association between maternal antenatal depression score and offspring psychotic experiences was similar in size to that between maternal antenatal depression score and offspring depression at 18 years of age.
The strengths of this study include the longitudinal design, large sample size, long-term follow-up period, and the availability of data on a broad range of confounders. Maternal depression was assessed several times during pregnancy and the postnatal period, and a reliable semi-structured interview was used to assess offspring psychotic experiences.
Attrition is a limitation of this study, as with all cohort studies, and can introduce selection bias; however, multiple imputation was used to investigate the likely impact of attrition and did not alter our conclusions.
Previous work in ALSPAC has shown that within-cohort associations tend to be valid even when there are differences between the study sample and the target population,26 and, when investigating risk factors, a representative sample is not so important as long as the effects of attrition are minimised.27
Although this study was of only one national population, we hope that it will generate future research including cross-cultural comparisons. Genetic confounding must be considered because there is evidence of shared genetic liability between psychotic experiences and a range of other psychiatric disorders.28
However, adjusting for maternal family history of psychosis in the main analyses and for paternal family history of psychosis in sensitivity analyses showed no effect. Sensitivity analyses for family history of bipolar disorder and history of mental health admission also showed no effect.
Maternal depression measurement was by self-report questionnaire; however, EPDS has been validated against longer assessments and any random measurement error would tend to reduce the size of association rather than lead to spurious associations.
In keeping with the vast majority of studies using the PLIKSi, this study used the measure as a binary variable. Although it is more statistically appropriate to model data from the PLIKSi as a binary outcome, psychotic experiences are in reality continuous in the general population.
This study was not able to examine the differential effects of maternal antenatal and postnatal depression due to the correlation between them. Antenatal depression might exert an effect through biological mechanisms acting in utero or after birth through effects on parenting.
During pregnancy, maternal depression, which might be a reflection of chronic maternal stress, could affect glucocorticoids, which might have effects on placental function, fetal development, epigenetics, and immune function, all of which have been implicated in the aetiology of psychotic disorders.4, 29
To investigate such potential mechanisms future research could use measures of hypothalamopituitary axis activation, such as cortisol concentration antenatally.
Recent findings in the FinnBrain cohort show changes in maternal cortisol concentration 30 and cytokine profiles 31 associated with antenatal depressive symptom trajectories.
A mechanism involving immune function would be consistent with findings that maternal infection during pregnancy is a potential risk factor for schizophrenia, particularly in the offspring of parents with a psychiatric disorder.32
Maternal depression during pregnancy has also been linked to an increased risk of pregnancy and delivery complications,4 which have been linked to psychotic experiences at the age of 12 years in this cohort.24
Maternal antenatal depression might also interfere with maternal postnatal bonding with the infant33 as well as with maternal representations of the unborn child that are associated with mother–infant interactions34 in the early postnatal period.
By contrast, postnatal depression could affect environmental factors such as parenting and wider social engagement.4
Infancy is a period of extreme dependency on the caregiver as well as rapid development and is a vulnerable period during development. Psychotic experiences are an important area of interest because they not only represent the milder end of the psychosis continuum and thereby psychotic disorders1 but are also associated with more severe presentations of depression and anxiety.2
Our evidence suggests that mothers with depression during the perinatal period are more likely to have offspring with psychotic experiences during their adolescence. Our study extends the growing list of childhood and adolescent outcomes associated with perinatal depression.
It suggests that common developmental mechanisms might underlie the risk of many psychiatric disorders and adds weight to the importance of identifying and treating maternal mental health problems during pregnancy and the postnatal period, especially in view of evidence that they might be increasing in the current generation of young women.22
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