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Published in final edited form as: J Psychiatr Res. 2023 Dec 18;170:130–137. doi: 10.1016/j.jpsychires.2023.12.020

Increased postpartum anxiety symptoms after perinatal SARS-CoV-2 infection in a large, prospective pregnancy cohort in New York City

Juliana Castro a,1, Frederieke AJ Gigase a,b,1,*, Nina M Molenaar a,f, Erona Ibroçi a, M Mercedes Perez-Rodriguez a, Whitney Lieb c,d,e, Teresa Janevic c,e, Lot D de Witte a, Veerle Bergink a,c,f, Anna-Sophie Rommel a
PMCID: PMC10905645  NIHMSID: NIHMS1970547  PMID: 38134722

Abstract

Numerous studies reported an increase of postpartum mood symptoms during the COVID-19 pandemic. Yet, the link between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and perinatal mental health is less well understood. We investigated the associations between prenatal SARS-CoV-2 infection and postpartum depressive and anxiety symptoms, including examinations of infection timing and pandemic timeline. We included 595 participants from Generation C, a prospective pregnancy cohort in New York City (2020–2022). Prenatal SARS-CoV-2 infection was determined via laboratory or medical diagnosis. Depression and anxiety symptoms were measured 4–12 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder questionnaire (GAD), respectively. Quantile regressions were conducted with prenatal SARS-CoV-2 infection as exposure and continuously measured EPDS and GAD scores as outcomes. We reran the analyses in those with COVID-19-like symptoms in the trimester during which infection occurred. 120 (20.1%) participants had prenatal SARS-CoV-2 infection. After adjusting for socio-demographic, obstetric and other maternal health factors, prenatal SARS-CoV-2 infection was associated with higher median postpartum anxiety scores (b = 0.55, 95% CI = 0.15; 0.96). Late gestation infection (b = 1.15, 95% CI = 0.22; 2.09) and symptomatic infection (b = 1.15, 95% CI = 0.12; 2.18) were also associated with higher median postpartum anxiety scores. No associations were found with depressive symptoms. The associations were not moderated by time since the start of the pandemic. This study suggests that prenatal SARS-CoV-2 infection increases the risk of postpartum anxiety symptoms among participants reporting median anxiety symptoms. Given that this association was not affected by pandemic timing and that SARS-CoV-2 transmission continues, individuals infected with SARS-CoV-2 during pregnancy should be monitored for postpartum anxiety symptoms.

Keywords: COVID-19 pandemic, SARS-CoV-2, Prenatal infection, Postpartum depression, Postpartum anxiety, Perinatal mental health

1. Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic has affected mental health both indirectly via disruptive societal changes and more directly via neuropsychiatric sequelae after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (Schou et al., 2021; Ventriglio et al.). Meta-analyses on the mental health impact of the COVID-19 pandemic in the general population have consistently shown a small but significant increase in self-reported depression and anxiety symptoms, with pooled effect sizes ranging from 0.15 to 0.20 and from 0.13 to 0.16, respectively (Prati and Mancini, 2021; Robinson et al., 2022). A number of large-scale studies further suggested that the increase in mental health problems was greatest in the initial months of the pandemic and attenuated over time as infection rates decreased and social restrictions lifted (Robinson et al., 2022; Varga et al., 2021; Fancourt et al., 2021). Among women, the increases in mental health problems in response to the COVID-19 pandemic were reported to be between 44% and 75% higher than in men (Robinson et al., 2022; Kunzler et al., 2021; Patel et al., 2022; Santomauro et al., 2021). These findings may reflect greater vulnerability to mood symptoms or increased disruptions to daily life in women compared to men due to, for example, greater childcare responsibilities, employment loss and/or gender-based violence (Flor et al., 2022).

Perinatal individuals are particularly vulnerable to mental health problems, with annual pre-pandemic incidence rates for postpartum depression and anxiety in new US mothers ranging between 10% and 15% (Halbreich and Karkun, 2006). Depression and anxiety in the postpartum period put mothers at increased risk of experiencing negative mental and physical health outcomes, relationship difficulties, poor mother–infant interactions, and poorer child outcomes, including adverse birth outcomes and long-term cognitive, social and behavioral problems (Slomian et al., 2019). Risk factors for postpartum depression and anxiety include both physiological and psychosocial factors (Beck, 2006; Dye et al., 2022). A direct effect of SARS-CoV-2 infection on postpartum mental health is conceivable since the immune system goes through large-scale dynamic shifts during and after pregnancy, and infections and immune-related mechanisms are thought to play an important role in triggering or exacerbating postpartum psychiatric symptoms (Osborne et al., 2019; Sherer et al., 2018). In line with this idea, neuropsychiatric symptoms among patients with severe COVID-19 have been correlated with serum levels of inflammatory markers, (Mazza et al., 2020) and have also been linked to alterations in brain structure and functioning (Qin et al., 2021; Douaud et al., 2022; Tian et al., 2022; Lu et al., 2020). In addition, maternal distress might be compounded by concerns regarding the risk of infection or hospitalization due to COVID-19, especially as perinatal morbidity and mortality, as well as adverse child outcomes, have been reported in association with COVID-19 (Allotey et al., 2020).

A wealth of studies has assessed the perinatal mental health impact of the COVID-19 pandemic and reported that pandemic-related distress was associated with an increased risk of postpartum mental health symptoms (Lebel et al., 2020; Farrell et al., 2020; Fallon et al., 2021; Basu et al., 2021). Yet, most cross-sectional studies of the perinatal mental health impact of the COVID-19 pandemic did not assess or confirm SARS-CoV-2 infection status, (Farrell et al., 2020; Fallon et al., 2021; Bo et al., 2021; Effati-Daryani et al., 2020) despite anxiety and depression being among the most prevalent neuropsychiatric symptoms associated with COVID-19 in the general population (51 studies; N = 18, 917; mean follow-up: 77 days [range: 14–182 days]), with a pooled prevalence of 19.1% for anxiety symptoms and 12.9% for depressive symptoms (Badenoch et al., 2022). Hence, the link between SARS-CoV-2 infection and perinatal mental health is less well understood. The few studies that have investigated this question were limited by small sample size (Kotabagi et al., 2020), unknown infection timing (Ceulemans et al., 2021) or a very brief mood symptom assessment (Kim et al., 2022), and the results of these studies are conflicting. One small pilot study (N = 28; n = 14 COVID-19 positive; n = 14 COVID-19 negative) (Kotabagi et al., 2020) and one cross-national web-based study of 56 breastfeeding individuals (Ceulemans et al., 2021) found no association between SARS-CoV-2 infection and postpartum anxiety and depressive symptoms. Another study, which included a prospective and a retro-spective cohort (N = 3819 pregnant and postpartum participants; n = 771 COVID-19 positive; n = 3048 COVID-19 negative), showed that postpartum individuals with moderate to severe COVID-19 had an increased risk of depressive (aRR = 1.12 to 1.72) and anxiety (aRR: 1.18 to 1.40) symptoms, while no increased risk was observed for mild or asymptomatic illness (Kim et al., 2022). None of these studies investigated infection timing during pregnancy, despite the third trimester seemingly playing a particularly important role in the association between immune-related mechanisms and postpartum mental health (Osborne et al., 2019). Furthermore, the pandemic timeline was not considered by any of these studies.

While the pandemic is now transitioning away from the acute phase of a global public health emergency, sustained transmission of SARS-CoV-2 will continue for the foreseeable future (World Health Organization, 2023). Examining the association between SARS-CoV-2 infection during pregnancy and postpartum psychopathology is, therefore, imperative. As public health restrictions and uncertainty in the early days of the pandemic may have exacerbated mental health problems, investigating the effect of pandemic timing on this association will shed a light on the current potential need for clinical attention and targeted mental health intervention in the postpartum period following prenatal SARS-CoV-2 infection.

The aim of this study was to investigate the association between prenatal SARS-CoV-2 infection and depressive and anxiety symptoms 4–12 weeks postpartum in a large, prospective pregnancy cohort assessed in New York City (NYC) between April 2020 and October 2022. Moreover, we aimed to examine if the time since the start of the pandemic moderates the association between SARS-CoV-2 infection and postpartum depressive and anxiety symptoms, and how SARS-CoV-2 infection timing during pregnancy, i.e., infection in early (<20 weeks) or late (≥ 20 weeks) gestation, affects postpartum depressive and anxiety symptoms.

2. Materials & methods

2.1. Study design and population

The Generation C Study is a prospective pregnancy cohort study conducted within the Mount Sinai Health System (MSHS), a large health care system in NYC. The study was described in detail elsewhere (Molenaar et al., 2022). Briefly, pregnant individuals (>18 years old) receiving obstetrical care in the MSHS were eligible for participation. Recruitment began in April 2020 and data collection concluded in October 2022. All participants provided informed consent. The study was approved by the Icahn School of Medicine at Mount Sinai Institutional Review Board (IRB-20-03352), reviewed by the US Centers for Disease Control and Prevention (CDC), and consistent with applicable federal law and CDC policy and in accordance with the Declaration of Helsinki. Exclusion criteria were incomplete data, delivery outside of the MSHS, multiple gestation, unknown infection status/infection outside of pregnancy, and postpartum questionnaire data before 4 weeks or after 12 weeks postpartum (Fig. 1). The final cohort for analysis comprised 595 pregnant participants. Patients’ demographic and clinical data, as well as pregnancy outcomes, were extracted from their electronic medical records (EMR) and can be found in Table 1. Demographics of included and excluded participants were compared and are presented in Supplementary Table 1

Fig. 1.

Fig. 1.

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Flowchart of the study sample. EPDS = Edinburgh Postnatal Depression Scale, GAD = General Anxiety Disorder Questionnaire, MSHS=Mount Sinai Health System.

Table 1.

Characteristics of participants enrolled in the Generation C study at the Mount Sinai Health System in New York City.

All (N = 595) SARS-CoV-2 infected during pregnancy (n = 120) No evidence of infection (n = 475) P-value*
Maternal age (years), mean (SD) 33.7 (4.7) 33.2 (4.7) 33.9 (4.7) 0.146a
Race-ethnicity, n (%) <0.001 b
 Asian 70 (11.8) 6 (5.0) 64 (13.5)
 Black or African American 61 (10.3) 23 (19.2) 38 (8.0)
 Hispanic 139 (23.4) 44 (36.7) 95 (20.0)
 White 300 (50.4) 42 (35.0) 258 (54.3)
 Any other race 25 (4.2) 5 (4.2) 20 (4.2)
Education, n (%) 0.002 b
 Until college 52 (8.7) 19 (15.8) 33 (6.9)
 College or above 543 (91.3) 101 (84.2) 442 (93.1)
Income (USD), n (%) <0.001 b
 <50 K 138 (23.2) 43 (35.8) 95 (20.0)
 50–100 K 95 (16.0) 24 (20.0) 71 (14.9)
 >100 K 357 (60.0) 52 (43.3) 305 (64.2)
 Missing 5 (0.8) 1 (0.8) 4 (0.8)
Insurance, n (%) 0.002 b
 Private/self-pay 493 (82.9) 88 (73.3) 405 (85.3)
 Public 102 (17.1) 32 (26.7) 70 (14.7)
NYC borough, n (%) 0.541b
 Manhattan 275 (46.2) 56 (46.7) 219 (46.1)
 Bronx 80 (13.4) 21 (17.5) 59 (12.4)
 Brooklyn 86 (14.5) 15 (12.5) 71 (14.9)
 Queens 62 (10.4) 12 (10.0) 50 (10.5)
 Staten Island 2 (0.3) 1 (0.8) 1 (0.2)
 Outside of NYC 90 (15.1) 15 (12.5) 75 (15.8)
Pre-pregnancy BMI (kg/m2), n (%) 0.002 b
 Underweight/normal weight (≥24.9) 300 (50.4) 49 (40.8) 253 (53.3)
 Overweight (25.0–29.9) 166 (27.9) 31 (25.8) 136 (28.6)
 Obesity (30 or higher) 121 (20.3) 38 (31.7) 84 (17.7)
 Missing 8 (1.3) 2 (1.7) 2 (0.4)
Marital status, n (%) 0.060
 Committed relationship (i.e., married, living with a partner, or in a relationship) 433 (72.8) 75 (62.5) 358 (75.4)
 Single 123 (20.7) 37 (30.8) 86 (18.1)
 Unknown/other 39 (6.6) 8 (6.7) 31 (6.5)
History of depression and/or anxiety, N (%) 133 (22.4) 26 (21.7) 107 (22.5) 0.840b
History of other mental health disorders, n (%) <0.001 b
 ADHD 8 (1.3) 0 8 (1.7)
 Autism Spectrum Disorder 1 (0.2) 0 1 (0.2)
 Bipolar Disorder 3 (0.5) 0 3 (0.6)
 Eating disorder 7 (1.2) 0 7 (1.5)
 OCD 3 (0.5) 0 3 (0.6)
 Schizophrenia 1 (0.2) 0 1 (0.2)
Received mental health treatment in the past year, n (%) 0.028 b
 Yes, namely: 84 (14.1) 7 (5.8) 77 (16.2)
 Therapy 40 (47.6) 3 (42.9) 37 (48.1)
 Medication 9 (10.7) 0 9 (11.7)
 Therapy and medication 35 (41.7) 4 (57.1) 31 (40.3)
COVID-like symptoms, n (%)
 ≥ 2 at any point in pregnancy 108 (17.6) 62 (51.7) 46 (9.7) <0.001 b
 ≥ 2 in trimester of infection 59 (9.9) 59 (49.2) N/A
COVID-19 severity, n (%) N/A
 Asymptomatic 9 (1.5) 9 (7.5) N/A
 Mild 23 (3.9) 23 (19.2) N/A
 Moderate 7 (1.2) 7 (5.8) N/A
 Severe 1 (0.2) 1 (0.8) N/A
 Missing 80 (13.4) 80 (66.7) N/A
Received COVID-19 vaccination, n (%) <0.001 b
 No proof of vaccination 290 (48.7) 36 (30.0) 254 (53.5)
 Yes, at least one dose during pregnancy 67 (11.3) 11 (9.2) 56 (11.8)
 Yes, all doses prior to pregnancy 237 (39.8) 72 (60.0) 165 (34.7)
 Missing 1 (0.2) 0 (0.0) 1 (0.2)
Parity, n (%) 0.004 b
 Nulliparous 318 (53.4) 50 (41.7) 268 (56.4)
 Multiparous 277 (46.6) 70 (58.3) 207 (43.6)
GA delivery (days), median (IQR) 274 (11.0) 274 (16.0) 274 (11.0) 0.473c
Preterm Birth, n (%) 45 (7.6) 9 (7.5) 36 (7.6) 0.801b
Birthweight (grams), median (IQR) 3240.1 (605.0) 3259.9 (645.0) 3229.9 (604.1) 0.956c
Delivery mode, N (%) 0.281b
 Vaginal, spontaneous 340 (57.1) 67 (55.8) 273 (57.5)
 Vaginal, assisted 36 (6.1) 4 (3.3) 32 (6.7)
 C-section 219 (36.8) 49 (40.8) 170 (35.8)
Mother-Child bonding, median (IQR)a 1 (3) 1 (3) 1 (2) 0.286c
Postpartum mental health
EPDS, median (IQR) 3 (6.0) 3 (5.0) 3 (6.0) 0.633c
EPDS cut-off (≤ 13), n (%) 48 (8.1) 13 (10.8) 35 (7.4) 0.213b
GAD, median (IQR) 2 (4.0) 2 (5.0) 2 (4.0) 0.617c
GAD cut-off (≤ 11), n (%) 30 (5.0) 9 (7.5) 21 (4.4) 0.168b
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*

P-values are comparing infected vs never infected.

Independent samples t-testa, Pearson Chi-Squareb or Mann-Whitney U-testc, was used as appropriate.

EPDS = Edinburgh Postnatal Depression Scale, GAD = General Anxiety Disorder Questionnaire, OCD=Obsessive Compulsive Disorder.

a

Lower scores indicate better mother-child bonding (Taylor et al., 2005).

2.2. Postpartum depressive and anxiety symptoms

Participants completed a survey about sociodemographic and lifestyle factors, medical history, and mental health around six weeks postpartum (range: 4–12 weeks, median = 7 weeks after birth). We used the Edinburgh Postnatal Depression Scale (EPDS), a validated 10-item self-rating scale, to screen for depressive symptoms (Bergink et al., 2011), and the Generalized Anxiety Disorder questionnaire (GAD), a validated 7-item self-rating scale, to evaluate anxiety symptoms (Spitzer et al., 2006). In our analyses, EPDS and GAD scores were used continuously. Higher scores indicate more depressive and anxiety symptoms, respectively. We further report the number of individuals with clinically meaningful depressive and anxiety symptoms as part of the demographic information. To maximize combined sensitivity and specificity, an EPDS cut-off score of ≤ 13 (where the cut-off was between 12/13) was used to identify clinically meaningful depressive symptoms (Hewitt et al., 2009; Levis et al., 2020). To establish clinically meaningful anxiety symptoms, we used a GAD cut-off score of ≤ 11 (where the cut-off was between 10/11) (Spitzer et al., 2006). Between May 2021–November 2021, no GAD data were collected due to a change in protocol, which resulted in a lapse of GAD data between 60 and 85 weeks after the start of the pandemic. This gap does not exist in EPDS scores because, in addition to self-report, these were extracted from the EMR. EPDS data was complete for N = 589 participants. GAD data was complete for 504 participants.

2.3. SARS-CoV-2 infection status and timing

Blood samples were obtained as part of routine blood draws during prenatal visits or admission to labor and delivery. Samples were processed within 4 h (median = 1.6 h; IQR = 1.7 h). Plasma aliquots were stored at −80 °C until further analysis. Participant SARS-CoV-2 infection status and date were ascertained through 1) positive PCR test results during pregnancy; 2) anti-S IgG antibody presence using a serologic enzyme-linked immunosorbent assay (ELISA) developed at the Icahn School of Medicine at Mount Sinai (Stadlbauer et al., 2020) and one of the following: a) anti-S IgG antibody before an individual’s first COVID-19 vaccination, b) anti-S IgG antibody before the COVID-19 vaccination rollout in NYC (December 14, 2020), c) anti-S IgG antibody presence and anti-nucleocapsid (N) IgG antibodies using the MILLIPLEX® SARS-CoV-2 Antigen Panel 1 IgG from Millipore to confirm that antibodies were due to natural infection (Young et al., 2020), or d) anti-S IgG antibody after prior negative antibody result (seroconversion); the date the sample was collected was considered as the date of infection; or 3) diagnosis by a medical health official reported in the EMR and/or questionnaire. Pregnant people were considered never infected if they had no evidence of SARS-CoV-2 infection according to any of the items listed above. Moreover, data on COVID-19 symptoms were extracted from the participants’ surveys and EMRs. We considered a combination of two or more COVID-19-like symptoms (fever or chills, cough, shortness of breath or new loss of taste and/or smell) in the trimester in which infection occurred as symptomatic for COVID-19 (National Institute of Healtha; Roland et al., 2020). Disease severity was obtained from the EMR when available and defined according to the criteria outlined by the National Institute of Health. (National Institute of Healthb) Thus, asymptomatic infection was defined as having a positive virologic test for SARS-CoV-2 but having no symptoms consistent with COVID-19. Mild illness was defined as having any of the various signs and symptoms of COVID-19 (e.g., fever, cough, loss of taste and smell) but no shortness of breath, dyspnea, or abnormal chest imaging. Moderate illness was defined as having evidence of lower respiratory disease during clinical assessment or imaging and an oxygen saturation measured by pulse oximetry (SpO2) ≥ 94% on room air at sea level. Severe illness was defined as having SpO2 <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mm Hg, a respiratory rate >30 breaths/min, or lung infiltrates >50%. Critical illness was defined as having respiratory failure, septic shock, and/or multiple organ dysfunction (National Institute of Healthb).

2.4. Covariates

Covariates were chosen a priori based on literature suggesting the involvement of these covariates in postpartum mental health prior to and during the Covid-19 pandemic. Covariates included maternal age categorized by advanced maternal age (AMA) status (18–34 years, 35–49 years), history of depression and/or anxiety (yes, no), race and ethnicity (Asian, Black, Hispanic, White, Any other race), pre-pregnancy body mass index (BMI; underweight/healthy weight (<18.5–24.9), overweight (25.0–29.9), obesity (>30)), education (high school or less; college and above), parity (nulliparous, multiparous), preterm birth (<37 weeks’ gestation; yes, no), timing of EPDS/GAD assessment (postpartum weeks), and COVID-19 vaccinated (yes, during pregnancy; yes, before pregnancy; no) (Allotey et al., 2020; Molenaar et al., 2022; Martini et al., 2015; Muraca and Joseph, 2014; Silverman et al., 2018; Liu and Tronick, 2013; Janevic et al., 2022; de Paula Eduardo et al., 2019). Time since the start of the pandemic (number of weeks between March 1, 2020 [first confirmed SARS-CoV-2 infection in NYC] and birth) was included as covariate in the main model and further tested as moderator in the association between prenatal SARS-CoV-2 infection and postpartum mood symptoms. In addition, information was collected on marital status, history of mental health disorders, mental health treatment and mother-child bonding and incorporated in Table 1. Data was collected through questionnaires and data extraction from the EMR.

2.5. Statistical analysis

Demographics and obstetric outcomes were compared between participants with SARS-CoV-2 infection during pregnancy and never infected participants using independent samples t-test for normally distributed continuous variables, Mann-Whitney U test for non-normally distributed continuous variables, and Pearson’s Chi-square for categorical variables. Spearman’s rho correlation coefficients are reported. The associations between SARS-CoV-2 infection, and continuously measured postpartum EPDS and GAD scores were assessed using multivariate quantile regression models for the 25th, 50th, and 75th percentiles to allow for the analysis of non-normally distributed EPDS and GAD scores on a continuous scale (Shapiro-Wilk test of normality p < 0.001). In addition, we added an interaction term between SARS-CoV-2 infection status and time since the start of the pandemic to investigate whether pandemic timing moderated the association. In sensitivity analyses, we repeated these analyses in 1) a subgroup of participants infected during early gestation (< 20 weeks) and 2) a subgroup of participants infected during late gestation (≥20 weeks), to assess whether infection timing affects postpartum depressive and anxiety symptoms differently, and 3) a subgroup of SARS-CoV-2 infected participants reporting COVID-19-like symptoms during the trimester in which SARS-CoV-2 infection occurred. Regression models were adjusted for the covariates listed above. All analyses were conducted using SPSS 28.0 (IBM SPSS Statistics).

3. Results

3.1. Cohort characteristics

Of 595 participants, 120 (20.1%) participants had prenatal SARS-CoV-2 infection and 475 had no evidence of prior infection (79.8%). Of 120 SARS-CoV-2 infected participants, 59 (49.2%) reported two or more COVID-19-like symptoms during the trimester in which SARS-CoV-2 infection occurred. The median age of participants was 33.7 years (range 19–46 years). Participants with prenatal SARS-CoV-2 infection had lower levels of education, were older, and were more likely to be Hispanic or Black, publicly insured, and obese relative to those who had no evidence of prior SARS-CoV-2 infection (Table 1), in line with previously described ‘at risk’ populations (Janevic et al., 2022).

3.2. Prenatal SARS-CoV-2 infection and postpartum depressive symptoms (EPDS)

The median EPDS score was 3 (IQR = 6), with 48 (8.1%) participants scoring above the clinical cut-off for depression (≤ 13) (Table 1). Prenatal SARS-CoV-2 infection was not associated with EPDS scores 4–12 weeks postpartum (p > 0.05; Table 2; Fig. 2). The interaction of prenatal SARS-CoV-2 infection with time since the start of the pandemic was not significant (Supplementary Table 2). Sensitivity analyses showed no significant associations between early gestation infection (b = 0.67, 95% CI = −0.96; 2.29), late gestation infection (b = 0.33, 95% CI = −0.94; 1.61), or symptomatic infection (b = 0.52, 95% CI = −1.05; 2.10) and postpartum EPDS scores (Supplementary Tables 3–5).

Table 2.

The association between prenatal SARS-CoV-2 infection and EPDS and GAD scores postpartum (n = 595).

EPDS score (25% quantile) EPDS score (50% quantile) EPDS score (75% quantile)
Coefficient (95% CI) P-value Coefficient (95% CI) P-value Coefficient (95% CI) P-value
Unadjusted Infected during pregnancy (n = 120) 0.00 (−0.38; 0.38) >0.999 0.00 (−0.70; 070) >0.999 −0.50 (−1.25; 0.25) 0.191
Adjusted Infected during pregnancy (n = 120)a 0.00 (−0.44; 0.44) >0.999 0.17 (−0.43; 0.76) 0.581 0.30 (−0.47; 1.07) 0.442
GAD score (25% quantile) GAD score (50% quantile) GAD score (75% quantile)
Coefficient (95% CI) P-value Coefficient (95% CI) P-value Coefficient (95% CI) P-value
Unadjusted Infected during pregnancy (n = 120) 0.00 (−0.19; 0.19) >0.999 0.00 (−0.43; 0.43) >0.999 0.50 (−0.08; 1.08) 0.090
Adjusted Infected during pregnancy (n = 120)a 0.00 (0.00; 0.00) >0.999 0.55 (0.15; 0.96) 0.008 0.28 (−0.37; 0.93) 0.398
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a

Adjusted for covariates: history of depression and/or anxiety (yes, no), race and ethnicity (Asian, Black or African American, Hispanic, White, Any other race), pre-pregnancy BMI (underweight/normal weight (<18.5–24.9), overweight (25.0–29.9), obesity (>30)), education (high school or less; college and above), parity (nulli-, multiparous), preterm birth (yes, no), timing of EPDS/GAD-7 assessment (postpartum weeks), maternal age at delivery, vaccinated (yes; during pregnancy, yes; before pregnancy, no), time since start pandemic (weeks). Reference group is no evidence of infection (N = 475). EPDS = Edinburgh Postnatal Depression Scale, GAD = General Anxiety Disorder Questionnaire.

Fig. 2.

Fig. 2.

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EPDS and GAD scores postpartum (4–12 weeks) throughout the COVID-19 pandemic for SARS-CoV-2 infected participants (n = 120) and participants with no evidence of infection (n = 475). Solid lines indicate the relation between EPDS and GAD scores with the time since the start of the pandemic (first case in NYC on March 1st, 2020). Dotted lines represent 95% Confidence Intervals. EPDS = Edinburgh Postnatal Depression Scale, GAD = General Anxiety Disorder Questionnaire.

3.3. Prenatal SARS-CoV-2 infection and postpartum anxiety symptoms (GAD)

The median GAD score was 2 (IQR = 4), with 30 (5%) participants scoring above the clinical cut-off for generalized anxiety disorder (≤ 11) (Table 1). Prenatal SARS-CoV-2 infection was associated with higher median postpartum GAD scores (b = 0.55, 95% CI = 0.15; 0.96; Table 2; Fig. 2). The interaction of prenatal SARS-CoV-2 infection with time since the start of the pandemic was not significant (Supplementary Table 2). The covariates parity (b = −0.62, p = 0.048) and history of depression and/or anxiety (b = 1.73, p < 0.001) were significantly associated with GAD scores postpartum in fully adjusted models, suggesting that these factors are confounding the association between SARS-CoV-2 infection and postpartum anxiety symptoms. Sensitivity analyses showed that late gestation infection (b = 1.15, 95% CI = 0.22; 2.09) and symptomatic infection (b = 1.15, 95% CI = 0.12; 2.18) were positively associated with median postpartum GAD scores. While early pregnancy infection was not significantly associated with postpartum GAD scores, the direction and size of the effect was similar to that of late gestation infection (b = 1.10, 95% CI = −0.10; 2.29) (Supplementary Tables 3–5).

4. Discussion

In this large, prospective pregnancy cohort, we found an association between prenatal SARS-CoV-2 infection and increased median postpartum anxiety symptoms (50% percentile), which was particularly pronounced for those with late pregnancy infection and those reporting COVID-19-like symptoms in the trimester in which infection occurred. This association was not affected by the length of time between the outbreak of the pandemic and birth. SARS-CoV-2 infection during pregnancy was not associated with postpartum depressive symptoms. We also confirmed previous findings that, on average, participants with prenatal SARS-CoV-2 infection were older, had lower levels of education, and were more likely to be Hispanic or Black, publicly insured, and obese relative to those who had no evidence of prior SARS-CoV-2 infection (Molenaar et al., 2022; Janevic et al., 2022).

Unlike previous research, which reported associations between prenatal SARS-CoV-2 infection and postpartum anxiety symptoms only in moderate to severe cases of COVID-19,30–32 we demonstrated a link between prenatal SARS-CoV-2 infection and increased median anxiety symptoms in the postpartum period. Since our sample also included asymptomatic and mild cases, our results suggest that the association between prenatal SARS-CoV-2 infection and postpartum anxiety symptoms is not limited to severe cases. We found no association between prenatal SARS-CoV-2 infection and postpartum anxiety symptoms at the 25th and 75th percentiles, suggesting that among participants reporting low and high anxiety scores other factors may be at play that are not captured by the covariates included here. It is possible that other protective factors (e.g., social support) or stressors (e.g., negative life events) significantly impact anxiety symptoms in the postnatal period, outweighing the effects of prenatal SARS-CoV-2 infection in this group. Our findings are in line with a meta-analysis of 51 general population studies, which reported anxiety to be common and persistent following SARS-CoV-2 infection (Badenoch et al., 2022). We further found that infection in late rather than early gestation was associated with increased median anxiety symptoms postpartum. While our sample of individuals infected in early gestation was small and the lack of an association may be the result of limited power, the third trimester plays an important role in the relationship between immune activation and mood symptoms (Osborne et al., 2019). Thus, late gestation infection with SARS-CoV-2 may particularly impact postpartum anxiety symptoms. It is conceivable that prenatal SARS-CoV-2 infection, and in particular infection in late pregnancy and symptomatic infection, increases the distress and worries about infecting others including the baby, social isolation and lack of support related to quarantining in the weeks following delivery, or the long-term effects of prenatal infection on the child (Lebel et al., 2020; Farrell et al., 2020; Fallon et al., 2021; Basu et al., 2021). Future research should investigate potential mechanisms underlying the association between prenatal SARS-CoV-2 infection and postpartum anxiety symptoms.

The current study supports previous postpartum studies, which found no association between prenatal SARS-CoV-2 infection and postpartum depressive symptoms, at least in mild and asymptomatic patients (Kotabagi et al., 2020; Ceulemans et al., 2021; Kim et al., 2022). Perinatal and postpartum depression symptoms were also reported to be unaffected by the COVID-19 pandemic, whilst pregnancy-specific stress increased during the COVID-19 pandemic compared to before (Boekhorst et al., 2021). Depressive symptoms were also less likely to be reported as neuropsychological sequelae of COVID-19 in the general population than anxiety symptoms, (Badenoch et al., 2022) and pooled prevalence estimate of clinically relevant levels of depression have been found to be lower than those of anxiety symptoms during the COVID-19 pandemic (Dragioti et al., 2022). It is unclear why SARS-CoV-2 is associated with anxiety but not depressive symptoms in our sample.

Numerous large-scale studies suggested that the increase in population-level mental health problems was highest during the initial phase of the pandemic and smaller, albeit persistent, in subsequent months (Robinson et al., 2022; Varga et al., 2021; Fancourt et al., 2021). Direct associations were also found between levels of anxiety and depressive symptoms in the general population and the average number of daily COVID-19 cases in the US. (Jia et al., 2021) Nevertheless, we found no interaction between prenatal SARS-CoV-2 infection and the time since the start of the pandemic in this study. This finding could be due to the length of the follow-up, spanning more than 2.5 years from the outbreak of the pandemic to a slow return to normality where social restrictions were lifted and infection rates gradually decreased. Moreover, the results may have arisen from the potentially positive and protective changes ensuing from public health measures such as the lockdown and stay-at-home orders, which, for some, resulted in a better work–life balance, improved family dynamics and enhanced feelings of closeness (Radka et al., 2022; Cornell et al., 2022). Those factors may have increased the overall sense of well-being, thereby decreasing anxiety symptoms.

Major strengths of this study include the use of data from a large, diverse prospective pregnancy cohort and the use of data extending over 2.5 years beginning in April 2020, thus spanning the full breadth of public health measures and viral waves of the COVID-19 pandemic. However, the study also has limitations. First, our study lacks systematically collected data on COVID-19 symptom severity, which has been found to be an important predictor of postpartum mental health (Kim et al., 2022; Magnúsdóttir et al., 2022). However, infection status was ascertained prospectively and by various strategies, which afforded us the ability to capture asymptomatic as well as symptomatic cases. We consider this one of the strengths of this study since this may make our sample more representative of all infected pregnant individuals in the general population compared to studies looking only at symptomatic or hospitalized patients. Second, the size of our early gestation infection group was small, which likely impacted our power and the ability to detect an effect of early gestation infection on postpartum mood symptoms. Future research should confirm whether infection timing impacts postpartum mental health. Third, we used self-report measures to screen for anxiety and depressive symptoms. Responses may be impacted by the participant’s introspective ability and interpretation of the questions and should not be generalized to clinical diagnoses. Nevertheless, the EPDS and GAD are validated and widely used. Fourth, we only measured anxiety and depressive symptoms at one point in the postpartum period and are, thus, not able to assess whether mood symptoms changed over time. We did, however, control for the psychiatric history of major depression and generalized anxiety disorder. In addition, we did not obtain information on other protective or risk factors which may significantly impact anxiety symptoms and affect the association with SARS-CoV-2 infection. Finally, the study sample is a subsample of individuals from the Generation C cohort who responded to the online survey. The included and excluded participants differed with regard to maternal age, race/ethnicity, insurance type, history of mood disorders and prevalence of SARS-CoV-2 infection and COVID-19 vaccination during pregnancy. Thus, our findings may not be generalizable to the entire sample and further analyses may be needed to see how the results translate to the general population.

5. Conclusion

This prospective pregnancy study from New York City suggests that pregnant individuals exposed to SARS-CoV-2 during pregnancy are at increased risk of experiencing anxiety but not depressive symptoms in the postpartum period. Given that a) this association was not affected by pandemic timing and b) that SARS-CoV-2 transmission continues, future clinical attention is warranted for individuals infected with SARS-CoV-2 during pregnancy. Furthermore, strategies must be employed to address the need to increase resilience and resistance to infections and to prevent the spread of disease. Appropriate measures tailored to the individual may comprise the promotion of healthy lifestyle choices including getting enough rest and exercise, maintaining a balanced diet, and staying up to date with vaccination, while public health measures may include improved ventilation and air filtration in indoor public spaces and masking policies for those with respiratory illness.

Supplementary Material

Supplementary material

Footnotes

Declaration of competing interest

The Icahn School of Medicine at Mount Sinai has filed patent applications relating to SARS-CoV-2 serological assays and NDV-based SARS-CoV-2 vaccines which list Florian Krammer as co-inventor. Mount Sinai has spun out a company, Kantaro, to market serological tests for SARS-CoV-2. Florian Krammer has consulted for Merck and Pfizer (before 2020), and is currently consulting for Pfizer, Seqirus, 3rd Rock Ventures and Avimex and he is a co-founder and scientific advisory board member of CastleVax. The Krammer laboratory is also collaborating with Pfizer on animal models of SARS-CoV-2. M. Mercedes Perez-Rodriguez has received consulting fees from Alkermes, Inc and Neurocrine Biosciences, for work unrelated to this manuscript. The other authors have nothing to report.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpsychires.2023.12.020.

Data availability statement

Data are available upon request.

References

  1. Allotey J, Stallings E, Bonet M, et al. , 2020. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ 370, m3320. 10.1136/bmj.m3320. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Badenoch JB, Rengasamy ER, Watson C, et al. , 2022. Persistent neuropsychiatric symptoms after COVID-19: a systematic review and meta-analysis. Brain Commun. 4 (1), fcab297. 10.1093/braincomms/fcab297. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Basu A, Kim HH, Basaldua R, et al. , 2021. A cross-national study of factors associated with women’s perinatal mental health and wellbeing during the COVID-19 pandemic. PLoS One 16 (4), e0249780. 10.1371/journal.pone.0249780. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Beck CT, 2006. Postpartum Depression: it isn’t just the blues. AJN Am. J. Nurs 106 (5), 40–50. [DOI] [PubMed] [Google Scholar]
  5. Bergink V, Kooistra L, Lambregtse-van den Berg MP, et al. , 2011. Validation of the Edinburgh depression scale during pregnancy. J. Psychosom. Res 70 (4), 385–389. 10.1016/j.jpsychores.2010.07.008. [DOI] [PubMed] [Google Scholar]
  6. Bo HX, Yang Y, Chen J, et al. , 2021. Prevalence of depressive symptoms among pregnant and postpartum women in China during the COVID-19 pandemic. Psychosom. Med 83 (4), 345. 10.1097/PSY.0000000000000904. [DOI] [PubMed] [Google Scholar]
  7. Boekhorst MGBM, Muskens L, Hulsbosch LP, et al. , 2021. The COVID-19 outbreak increases maternal stress during pregnancy, but not the risk for postpartum depression. Arch. Womens Ment. Health 24 (6), 1037–1043. 10.1007/s00737-021-01104-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Ceulemans M, Foulon V, Ngo E, et al. , 2021. Mental health status of pregnant and breastfeeding women during the COVID-19 pandemic—a multinational cross-sectional study. Acta Obstet. Gynecol. Scand 100 (7), 1219–1229. 10.1111/aogs.14092. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Cornell S, Nickel B, Cvejic E, et al. , 2022. Positive outcomes associated with the COVID-19 pandemic in Australia. Health Promot. J. Aust 33 (2), 311–319. 10.1002/hpja.494. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. de Paula Eduardo JAF, de Rezende MG, Menezes PR, Del-Ben CM, 2019. Preterm birth as a risk factor for postpartum depression: a systematic review and meta-analysis. J. Affect. Disord 259, 392–403. 10.1016/j.jad.2019.08.069. [DOI] [PubMed] [Google Scholar]
  11. Douaud G, Lee S, Alfaro-Almagro F, et al. , 2022. SARS-CoV-2 is associated with changes in brain structure in UK Biobank. Nature 604 (7907), 697–707. 10.1038/s41586-022-04569-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Dragioti E, Li H, Tsitsas G, et al. , 2022. A large-scale meta-analytic atlas of mental health problems prevalence during the COVID-19 early pandemic. J. Med. Virol 94 (5), 1935–1949. 10.1002/jmv.27549. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Dye C, Lenz KM, Leuner B, 2022. Immune system alterations and postpartum mental illness: evidence from basic and clinical research. Front. Glob. Womens Health 2, 758748. 10.3389/fgwh.2021.758748. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Effati-Daryani F, Zarei S, Mohammadi A, Hemmati E, Ghasemi Yngyknd S, Mirghafourvand M, 2020. Depression, stress, anxiety and their predictors in Iranian pregnant women during the outbreak of COVID-19. BMC Psychol. 8 (1), 99. 10.1186/s40359-020-00464-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Fallon V, Davies SM, Silverio SA, Jackson L, De Pascalis L, Harrold JA, 2021. Psychosocial experiences of postnatal women during the COVID-19 pandemic. A UK-wide study of prevalence rates and risk factors for clinically relevant depression and anxiety. J. Psychiatr. Res 136, 157–166. 10.1016/j.jpsychires.2021.01.048. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Fancourt D, Steptoe A, Bu F, 2021. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. Lancet Psychiatr. 8 (2), 141–149. 10.1016/S2215-0366(20)30482-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Farrell T, Reagu S, Mohan S, et al. , 2020. The impact of the COVID-19 pandemic on the perinatal mental health of women. J. Perinat. Med 48 (9), 971–976. 10.1515/jpm-2020-0415. [DOI] [PubMed] [Google Scholar]
  18. Flor LS, Friedman J, Spencer CN, et al. , 2022. Quantifying the effects of the COVID-19 pandemic on gender equality on health, social, and economic indicators: a comprehensive review of data from March, 2020, to September, 2021. Lancet 399 (10344), 2381–2397. 10.1016/S0140-6736(22)00008-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Halbreich U, Karkun S, 2006. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J. Affect. Disord 91 (2), 97–111. 10.1016/j.jad.2005.12.051. [DOI] [PubMed] [Google Scholar]
  20. Hewitt C, Gilbody S, Brealey S, et al. , 2009. Methods to identify postnatal depression in primary care: an integrated evidence synthesis and value of information analysis. Health Technol. Assess 13 (36), 1–145. 10.3310/hta13360. [DOI] [PubMed] [Google Scholar]
  21. Janevic T, Lieb W, Ibroci E, et al. , 2022. The influence of structural racism, pandemic stress, and SARS-CoV-2 infection during pregnancy with adverse birth outcomes. Am. J. Obstetr. Gynecol. MFM 4 (4), 100649. 10.1016/j.ajogmf.2022.100649. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Jia H, Guerin RJ, Barile JP, et al. , 2021. National and state trends in anxiety and depression severity scores among adults during the COVID-19 pandemic - United States, 2020–2021. MMWR Morb. Mortal. Wkly. Rep 70 (40), 1427–1432. 10.15585/mmwr.mm7040e3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Kim S, Hernández-Díaz S, Zhu Y, Wyszynski D, Huybrechts KF, 2022. Association between SARS-CoV-2 infection during pregnancy and postpartum depressive and anxiety symptoms: finding from the International Registry of Coronavirus Exposure in Pregnancy (IRCEP) study. Arch. Womens Ment. Health 25 (6), 1105–1118. 10.1007/s00737-022-01274-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Kotabagi P, Nauta M, Fortune L, Yoong W, 2020. COVID-19 positive mothers are not more anxious or depressed than non COVID pregnant women during the pandemic: a pilot case-control comparison. Eur. J. Obstet. Gynecol. Reprod. Biol 252, 615–616. 10.1016/j.ejogrb.2020.07.037. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Kunzler AM, Röthke N, Günthner L, et al. , 2021. Mental burden and its risk and protective factors during the early phase of the SARS-CoV-2 pandemic: systematic review and meta-analyses. Glob. Health 17 (1), 34. 10.1186/s12992-021-00670-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Lebel C, MacKinnon A, Bagshawe M, Tomfohr-Madsen L, Giesbrecht G, 2020. Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. J. Affect. Disord 277, 5–13. 10.1016/j.jad.2020.07.126. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD, 2020. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ 371, m4022. 10.1136/bmj.m4022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Liu CH, Tronick E, 2013. Rates and predictors of postpartum depression by race and ethnicity: results from the 2004 to 2007 New York city PRAMS survey (pregnancy risk assessment monitoring system). Matern. Child Health J 17 (9), 1599–1610. 10.1007/s10995-012-1171-z. [DOI] [PubMed] [Google Scholar]
  29. Lu Y, Li X, Geng D, et al. , 2020. Cerebral micro-structural changes in COVID-19 patients - an MRI-based 3-month follow-up study. EClinMed. 25, 100484 10.1016/j.eclinm.2020.100484. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Magnúsdóttir I, Lovik A, Unnarsdóttir AB, et al. , 2022. Acute COVID-19 severity and mental health morbidity trajectories in patient populations of six nations: an observational study. Lancet Public Health 7 (5), e406–e416. 10.1016/S2468-2667(22)00042-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Martini J, Petzoldt J, Einsle F, Beesdo-Baum K, Höfler M, Wittchen HU, 2015. Risk factors and course patterns of anxiety and depressive disorders during pregnancy and after delivery: a prospective-longitudinal study. J. Affect. Disord 175, 385–395. 10.1016/j.jad.2015.01.012. [DOI] [PubMed] [Google Scholar]
  32. Mazza MG, De Lorenzo R, Conte C, et al. , 2020. Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors. Brain Behav. Immun 89, 594–600. 10.1016/j.bbi.2020.07.037. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Molenaar NM, Rommel AS, de Witte L, et al. , 2022. SARS-CoV-2 during pregnancy and associated outcomes: results from an ongoing prospective cohort. Paediatr. Perinat. Epidemiol 36 (4), 466–475. 10.1111/ppe.12812. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Muraca GM, Joseph KS, 2014. The association between maternal age and depression. J. Obstet. Gynaecol. Can 36 (9), 803–810. 10.1016/S1701-2163(15)30482-5. [DOI] [PubMed] [Google Scholar]
  35. National Institute of Health. COVID-19 treatment guidelines Panel. Coronavirus disease 2019 (COVID-19) treatment guidelines. COVID-19 treatment guidelines. Accessed May 17, 2023. https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/. [Google Scholar]
  36. National Institute of Health. Clinical spectrum of SARS-CoV-2 infection. COVID-19 treatment guidelines. Accessed May 17, 2023. https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/. [Google Scholar]
  37. Osborne LM, Yenokyan G, Fei K, et al. , 2019. Innate immune activation and depressive and anxious symptoms across the peripartum: an exploratory study. Psychoneuroendocrinology 99, 80–86. 10.1016/j.psyneuen.2018.08.038. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Patel K, Robertson E, Kwong ASF, et al. , 2022. Psychological distress before and during the COVID-19 pandemic among adults in the United Kingdom based on coordinated analyses of 11 longitudinal studies. JAMA Netw. Open 5 (4), e227629. 10.1001/jamanetworkopen.2022.7629. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Prati G, Mancini AD, 2021. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol. Med 51 (2), 201–211. 10.1017/S0033291721000015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Qin Y, Wu J, Chen T, et al. , 2021. Long-term microstructure and cerebral blood flow changes in patients recovered from COVID-19 without neurological manifestations. J. Clin. Invest 131 (8), e147329 10.1172/JCI147329, 147329. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Radka K, Wyeth EH, Derrett S, 2022. A qualitative study of living through the first New Zealand COVID-19 lockdown: affordances, positive outcomes, and reflections. Prev. Med. Rep 26, 101725 10.1016/j.pmedr.2022.101725. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Robinson E, Sutin AR, Daly M, Jones A, 2022. A systematic review and meta-analysis of longitudinal cohort studies comparing mental health before versus during the COVID-19 pandemic in 2020. J. Affect. Disord 296, 567–576. 10.1016/j.jad.2021.09.098. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Roland LT, Gurrola JG, Loftus PA, Cheung SW, Chang JL, 2020. Smell and taste symptom-based predictive model for COVID-19 diagnosis. Int. Forum Allergy Rhinol 10 (7), 832–838. 10.1002/alr.22602. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Santomauro DF, Herrera AMM, Shadid J, et al. , 2021. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet 398 (10312), 1700–1712. 10.1016/S0140-6736(21)02143-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Schou TM, Joca S, Wegener G, Bay-Richter C, 2021. Psychiatric and neuropsychiatric sequelae of COVID-19 - a systematic review. Brain Behav. Immun 97, 328–348. 10.1016/j.bbi.2021.07.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Sherer ML, Posillico CK, Schwarz JM, 2018. The psychoneuroimmunology of pregnancy. Front. Neuroendocrinol 51, 25–35. 10.1016/j.yfrne.2017.10.006. [DOI] [PubMed] [Google Scholar]
  47. Silverman ME, Smith L, Lichtenstein P, Reichenberg A, Sandin S, 2018. The association between body mass index and postpartum depression: a population-based study. J. Affect. Disord 240, 193–198. 10.1016/j.jad.2018.07.063. [DOI] [PubMed] [Google Scholar]
  48. Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O, 2019. Consequences of maternal postpartum depression: a systematic review of maternal and infant outcomes. Womens Health 15, 1745506519844044. 10.1177/1745506519844044. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Spitzer RL, Kroenke K, Williams JBW, Löwe B, 2006. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch. Intern. Med 166 (10), 1092–1097. 10.1001/archinte.166.10.1092. [DOI] [PubMed] [Google Scholar]
  50. Stadlbauer D, Amanat F, Chromikova V, et al. , 2020. SARS-CoV-2 seroconversion in humans: a detailed protocol for a serological assay, antigen production, and test setup. Curr. Protoc. Microbiol 57 (1), e100 10.1002/cpmc.100. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Taylor A, Atkins R, Kumar R, Adams D, Glover V, 2005. A new Mother-to-Infant Bonding Scale: links with early maternal mood. Arch. Wom. Ment. Health 8 (1), 45–51. 10.1007/s00737-005-0074-z. [DOI] [PubMed] [Google Scholar]
  52. Tian T, Wu J, Chen T, et al. , 2022. Long-term follow-up of dynamic brain changes in patients recovered from COVID-19 without neurological manifestations. JCI Insight 7 (4), e155827. 10.1172/jci.insight.155827. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Varga TV, Bu F, Dissing AS, et al. , 2021. Loneliness, worries, anxiety, and precautionary behaviours in response to the COVID-19 pandemic: a longitudinal analysis of 200,000 Western and Northern Europeans. Lancet Reg. Health Eur 2, 100020 10.1016/j.lanepe.2020.100020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Ventriglio A, Castaldelli-Maia JM, Torales J, Chumakov EM, Bhugra D. Personal and social changes in the time of COVID-19. Ir. J. Psychol. Med.:1–3. doi: 10.1017/ipm.2021.23.. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. World Health Organization, 2023. From Emergency Response to Long-Term COVID-19 Disease Management: Sustaining Gains Made during the COVID-19 Pandemic. Accessed May 17, 2023. World Health Organization. https://www.who.int/publications-detail-redirect/WHO-WHE-SPP-2023.1. [Google Scholar]
  56. Young MK, Kornmeier C, Carpenter RM, et al. , 2020. IgG antibodies against SARSCoV-2 correlate with days from symptom onset, viral load and IL-10. Published online December 7, 2020 medRxiv. 10.1101/2020.12.05.20244541, 12.05.20244541. [DOI] [Google Scholar]

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