Research reportExamining the relationship between antenatal anxiety and postnatal depression
Introduction
A range of psychological, socio-demographic and obstetric risk factors have been identified as important determinants of postnatal depression (PND) with anxiety a clearly identified domain (Matthey et al., 2003, Matthey, 2004, Austin, 2004; Sutter-Dallay et al., 2004, Heron et al., 2004). Antenatal anxiety has been found to be a significant predictor of postnatal depression in three meta-analyses (Beck, 2001, O'Hara and Swain, 1996, Robertson et al., 2004), and in one study a diagnosis of an anxiety disorder in pregnancy was associated with a three-fold increase in PND at 6 weeks (Sutter-Dallay et al., 2004). Studies have demonstrated that risk of PND increases with higher levels of self-reported anxiety in pregnancy (Heron et al., 2004) and with a previous history of anxiety disorder (Johnstone et al., 2001, Matthey et al., 2003). “Worry” – which in this article refers to dysfunctional trait cognitive anxiety – is an important cognitive component of anxiety and may be exacerbated during the antenatal period. While mild worry during pregnancy is considered both normal and adaptive, excessive or uncontrollable worry, regarding the delivery, the health and safety of the infant or the mother's concerns about her ability to parent, is likely to be indicative of more clinically significant anxiety and to be associated with negative outcomes, such as the development of an anxiety disorder or PND. To date, no studies have specifically examined whether antenatal “worry” (trait cognitive anxiety) is predictive of PND. The presence of high trait anxiety in pregnancy also has implications for the offspring, with a number of studies indicating that high maternal trait anxiety is associated with difficult infant temperament (Austin et al., 2005a) and behavioural difficulties in childhood (O'Connor et al., 2002).
Although a number of researchers have observed that the Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987), the most widely used measure of antenatal and postnatal depression, is also a measure of anxiety (Brouwers et al., 2001, Ross et al., 2003), there are only 3 items on this scale that specifically examine anxiety. The 40-item State Trait Anxiety Inventory (STAI; Spielberger et al., 1970) is often used to assess anxiety in pregnancy and the postnatal period, but there are no brief self-report anxiety measures that have been specifically developed for, and accessible in, clinical settings (Ross et al., 2003). To this end, Gladstone et al. (2005) recently developed a Brief Measure of Worry Severity (BMWS) to assess severe and dysfunctional trait cognitive anxiety, also termed “worry”.
The BMWS is an 8-item self-report questionnaire assessing worry severity and its impact on function (Gladstone et al., 2005). It was developed using several independent subject samples with a sample size totaling 1085: these were 273 patients with depression or anxiety; a non-clinical sample of 748 women being screened for risk of postnatal depression; and 28 medical students. The initial 26 worry items were subjected to a principal components analysis. This produced a single factor (accounting for 61% of the variance), whose structure was retained when examined in two independent samples. In both samples, a single worry factor was retained constituting 67.6% of the variance for the depression sample and 56.7% for the antenatal (non-clinical) sample. Strong internal consistency was demonstrated in the depression sample (coefficient alpha of 0.92) and there was good construct validity. As “worry” is likely to be the more discriminant component of anxiety during the antenatal period, the BMWS scale may have utility for identifying women at risk of anxiety disorders as well as PND.
The aims of the present study were: (1) to determine whether antenatal worry as measured by the BMWS is a significant predictor of postnatal depression; (2) to examine the psychometric properties of the BMWS in an antenatal sample; and (3) to compare the utility of the BMWS to the STAI trait anxiety scale in predicting PND.
Section snippets
Subjects
The subjects included in this study were part of a larger longitudinal study examining risk factors for PND and factors affecting obstetric outcome and infant temperament (see Austin et al., 2005a, for full description of study methodology). Overall, 2000 women from the Royal Hospital for Women in Sydney were recruited to participate in the longitudinal study. The present study included a sub-sample of 748 women who completed the BMWS during the third trimester of pregnancy.
Measures and procedures
Subjects completed
Results
Data were analysed using SPSS version 10. The means and standard deviations for the sample on all measures completed at baseline are presented in Table 1.
Discussion
The study findings indicate that the BMWS has good construct validity; scores on this scale correlate strongly with scores on other measures of anxiety (STAI), depression (EPDS) and perinatal risk (Pregnancy Risk Questionnaire) that have been used in the antenatal period (see Table 2).
The findings also demonstrate that women with high antenatal scores on the BMWS have significantly greater odds of developing PND than those with low scores. Thus women with high antenatal BMWS scores were
Conclusions
After controlling for the relevant confounders, antenatal scores on the BMWS emerged as a predictor of PND compared to the trait scale of the STAI, further supporting its predictive utility. Overall, this study provides preliminary evidence for the construct validity and predictive value of the BMWS for use in the antenatal period. With further replication, the BMWS may prove to be a useful tool for use in both clinical and research settings.
Acknowledgements
We wish to thank Karen Saint for data collection, Nicole Reilly for her careful preparation of the manuscript and the NHMRC (Program Grant 222708) for funding the project. The NSW Centre for Mental Health helped support the project by providing Institute and Infrastructure funding.
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