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. Author manuscript; available in PMC: 2025 Nov 1.
Published in final edited form as: Anxiety Stress Coping. 2024 Mar 25;37(6):811–821. doi: 10.1080/10615806.2024.2333377

Antenatal Anxiety Symptoms Outperform Antenatal Depression Symptoms and Suicidal Ideation as a Risk Factor for Postpartum Suicidal Ideation

Katherine Musacchio Schafer 1,2, Elizabeth Mulligan 1, Mary O Shapiro 2,3,4, Heather Flynn 1, Thomas Joiner 1, Greg Hajcak 1
PMCID: PMC12042954  NIHMSID: NIHMS1982606  PMID: 38523456

Abstract

Background and Objectives:

Suicidal ideation (SI) during the postpartum phase is linked with suicide, a leading cause of death during this period. Antenatal depression and anxiety symptoms have both been linked with increased risk for postpartum SI. However, research aimed at examining the relative contributions of antenatal anxiety and depression symptoms towards postpartum SI remains nascent. In this study, we investigated the relative contribution of antenatal anxiety symptoms, depression symptoms, and SI towards postpartum SI.

Design:

These data are from a longitudinal study in which American mothers were assessed during pregnancy and again at six- to eight weeks postpartum.

Methods:

Data were analyzed using correlations and logistic regression models.

Results:

Antenatal anxiety symptoms and antenatal depression symptoms were significantly correlated with postpartum SI. Results from a logistic regression model indicated that antenatal anxiety symptoms (T1; OR=1.185 [1.125, 1.245], p=.004), but not antenatal depression symptoms (T1; OR=1.018 [0.943, 1.093], p=.812) or antenatal SI (T1; OR=1.58 [0.11, 22.29], p=0.73), were significantly associated with postpartum SI.

Conclusions:

Antenatal anxiety symptoms, depression symptoms, and SI were positively associated with postpartum SI. When examined simultaneously, anxiety symptoms during the antenatal phase (but not depression symptoms or SI) predicted SI in the postpartum phase.

Keywords: postpartum suicidal ideation, antenatal anxiety, antenatal depression, antenatal suicidal ideation, longitudinal

In comparison to other developed countries, maternal mortality in the United States is high (Tikkanen et al., 2020), with rates increasing by 30.8% from 2018 to 2020 (Centers for Disease Control and Prevention [CDC], 2022), with maternal mortality particularly prevalent in states such as Georgia (28.8 per 100,000 live births), Texas (22.9 per 100,000 live births), and New Jersey (24.1 per 100,000 live births; CDC, 2021). Given these increased rates, reducing maternal morbidity has become a clinical and public health priority (CDC, 2021). Outside of obstetric-related problems, one of the leading causes of death among antenatal (i.e., pregnant) and postpartum women is suicide. For example, Goldman-Mellor and Margerison (2019) found that death by suicide was the seventh leading cause of death among women who had recently given birth. In addition to death by suicide, suicidal ideation (SI), or thoughts about killing oneself, is also high among perinatal mothers, with a recent meta-analysis (Xiao et al., 2022) finding a SI rate of 10% in pregnancy and 7% in postpartum. SI is particularly worrisome in that SI always or nearly always precedes suicide death (Klonsky & May, 2018; O’Conner, 2011; Van Orden et al., 2012). Given the high rates of SI and death by suicide observed among pregnant and postpartum women, identifying factors associated with these phenomena is incredibly important as it may point to additional treatment targets that could be reduced via therapy.

One such factor is depression. Depression is characterized by low mood, anhedonia, and a variety of additional symptoms heterogeneous across individuals (e.g., appetite and sleep changes, feeling worthless or guilty; American Psychiatric Association, 2022). Antenatal depression, or depression symptoms in the months preceding delivery, is fairly common, with research indicating that there is a prevalence rate of approximately 10–15% among pregnant women (Anokye et al., 2018). Depression during the antenatal period represents a serious threat during a vulnerable time. Furthermore, depression in the antenatal period has been posited to stem from a rapid shift in the activities in structures and systems of the brain (e.g., amygdala, Duan et al., 2019; Jones et al., 2017; HPA Axis, Dickens & Pawluski, 2018). Antenatal depression has been prospectively linked with reduced positive feelings toward offspring (Young, 2013), premature termination of breastfeeding (Hamdan & Tamim, 2012), disturbances in child development (Quevedo et al., 2012), relationship dissatisfaction (Odinka et al., 2018), and poor family cohesion (Letourneau et al., 2012). The extant literature has established a significant and substantial link between depression and SI and death more broadly, as well as among perinatal women (e.g., Bodnar-Deren et al., 2016; Gressier et al., 2016; Patel et al., 2012; Paris et al., 2009). For example, a meta-analysis of 129 studies (Orsolini et al., 2016) found that mothers with severe depression during pregnancy were significantly more likely to report having experienced postpartum SI.

In addition to the established link between antenatal depression and postpartum SI, more recent research has linked antenatal anxiety with postpartum SI. Anxiety during the perinatal period can look different across people, but feeling scared or tensed, being worried most of the time (e.g., persistent thoughts about baby’s safety or well-being), and experiencing panic attacks are common symptoms reported by women (e.g., Wenzel et al., 2005; Brockington et al., 2006). Although the link between antenatal anxiety and postpartum SI is not as well characterized, recent research has found significant associations between these constructs (e.g., Bodnar-Deren et al., 2016; Skouteris et al., 2009). A recent meta-analysis of 13 studies found that antenatal anxiety nearly doubled the risk of postpartum suicide (Grigoriadis et al., 2019). Indeed, the link between antenatal anxiety and postpartum depression is important and the strength of that relationship had not yet been fully conceptualized or appreciated (Grigoriadis et al., 2019). Findings such as these are important given that they establish anxiety symptoms as an additional modifiable factor outside of depression symptoms that may be used to identify those at risk for SI and/or death by suicide during the postpartum phase.

This Study

While not every pregnancy is afflicted with anxiety and depression, taken together, the extant literature suggests significant relationships between antenatal depression and postpartum SI (Orsolini et al., 2016), as well as antenatal anxiety and postpartum SI (Grigoriadis et al., 2019) such that when studied independently antenatal anxiety and depression nearly doubled the risk of postpartum SI. However, it is unclear the extent to which antenatal anxiety contributes to postpartum SI above and beyond antenatal depression, a construct historically linked with postpartum SI. Indeed, the co-occurrence of anxiety and depression in perinatal women is high, much more so than in the broader population (Howard et al., 2023). Furthermore, it is unclear how antenatal anxiety and depression symptoms together contribute to the development of postpartum SI. Given the paucity of research linking antenatal anxiety symptoms and postpartum SI, the current study examined the relationship between antenatal depression symptoms, antenatal anxiety symptoms, antenatal SI, and postpartum SI. Based on previous research, we hypothesized that antenatal depression symptoms would significantly predict higher levels of SI during the postpartum phase (Bodnar-Deren et al., 2016; Gressier et al., 2016; Grigoriadis et al., 2019; Orsolini et al., 2016; Patel et al., 2012; Paris et al., 2009), Moreover, based on more recent work (Bodnar-Deren et al., 2016; Skouteris et al., 2009), we hypothesized that antenatal anxiety symptoms would also predict higher levels of SI during the postpartum phase. Finally, to extend previous research, we were also interested in better understanding the relative contribution of antenatal anxiety symptoms, antenatal depression symptoms, and antenatal SI in relation to postpartum SI. Given the dearth of research on antenatal anxiety symptoms, depression symptoms, and SI with postpartum SI, we did not make hypotheses for this analysis.

Method

Participants

Women (n = 276) participated in questionnaires during pregnancy between 8 and 38 gestational weeks (mean gestational weeks = 20.30, SD = 6.77). Of these women, 234 women also participated in online follow-up questionnaires at approximately 6 to 8 weeks postpartum. As such, the present study sample consists of 276 women. Participants were provided monetary compensation for their participation. Average weeks postpartum at the postpartum session was 6.91 (SD = 2.42). Informed consent was obtained before participation and the project was approved by the Institutional Review Board at the Florida State University.

The mean age of the sample was 30.19 years (SD = 5.13 years), with an annual income of $84,887.22 (SD = $98,565.27). At baseline, the participants were at an average gestational period of 20.53 weeks (SD = 6.75 weeks). On average participants delivered their children at 38.84 gestational weeks (SD = 2.24 weeks). The average follow-up was conducted at 6.91 weeks post-partum (SD = 2.42 weeks). The sample was diverse with regards to race (Asian = 1.3%, Black = 20.5%, White = 67.1%, Hispanic = 7.3%, Pacific Islander = 0.4%, and More than one race = 3.4%).

The current study was part of a larger longitudinal investigation of perinatal women recruited from a community Obstetrics and Gynecology clinic in Tallahassee, Florida. Participants completed questionnaires during their pregnancies and again at six to eight weeks postpartum. Previous work has been published using neural connectivity data from this dataset (Mulligan et al., 2022; Mulligan and Hajcak, 2022; Mulligan et al., 2021; Mulligan et al., 2018).

This is a crucial time period as previous research has found that PPA, PPD, and PPSI can be especially severe in the six weeks following birth (Lim et al., 2020). The purpose of the larger study was to examine neural (i.e., EEG) and psychosocial predictors of risk for perinatal depression in unselected pregnant participants in the community. Results of the neurophysiological assessments are published separately (Mulligan et al., 2019; Mulligan et al., 2021; Mulligan et al., 2022). Participants were excluded if they were non-English speaking or planning to move out of the local area during the time frame of the longitudinal study. Pregnant participants were recruited from a local OB/GYN office in Tallahassee, FL. Patients were provided with a study flyer at the office check-in desk, and patients who reported interest in the study were contacted by study coordinators who explained the procedures and details of the study. Participants were compensated $20 per hour for their time spent completing the study procedures.

Materials

Patient Health Questionnaire (PHQ-9):

The PHQ-9 is a 9-item self-report questionnaire that scores each of the nine DSM-IV criteria for depressive disorders over the past two weeks from “0” (not at all) to “3” (nearly every day). The PHQ-9 is a widely used measure of depression severity that is both reliable and valid (Kroenke et al., 2001), including during the perinatal period (Flynn et al., 2011; Yawn et al., 2009). Cronbach’s alpha for the PHQ-9 was .85. The PHQ-9 was used to assess postpartum suicidal ideation in the current study. Specifically, we used the score on item 9 (i.e., “Thoughts that you would be better off dead or of hurting yourself in some way”) as a measure of SI. This is item was scored on a scale from 0 to 3. Any score over zero was operationalized as SI being present. A score of zero was operationalized as SI being absent. The literature demonstrates support for single-item assessments of SI. With regards to the validity of single-item measures of SI, single-item measures of SI have been used in the prediction of suicide-related outcomes. For example, Green et al. (2015) employed a single-item SI measure, albeit from the BDI-II questionnaire (Beck et al., 1996), to predict both deaths by suicide and repeat suicide attempts (N = 5,200 psychiatric outpatients; N = 119 outpatients with histories of at least one recent suicide attempt). Single-item SI measures have also been used as the outcome variable in longitudinal prediction studies. For example, Joiner et al. (2022) recently predicted SI using a single-item metric from three specific behavioral facets of eating disorders (i.e., purging, binge eating, restricting) again using the BDI-II. Furthermore, even after an entire course of treatment for eating pathology, the single-item measure of SI used in Joiner et al. (2022) showed test-retest reliability clearly in the range of established multi-item measures (r = .47, p < .001).

However, single item measurement of SI is a significant limitation within this project that should be noted, with implications to particularly to statistical interpretations. For example, with a single item measurement of SI, statistical power to detect an association between the independent variables (i.e., peri-partum psychopathology) and the dependent variable (i.e., post-partum SI) is reduced. Likewise, with a dichotomous variable, variation in SI is almost entirely reduced, with variability collapsed into present/absent. Indeed, with a dichotomous measurement of SI the severity, frequency, and content of the SI within these patients is excluded from investigation.

Depression, Anxiety, and Stress Scales (DASS-21):

Antenatal symptoms of depression and anxiety were assessed using the Depression Anxiety Stress Scales (DASS-21; Lovibond & Lovibond, 1995). The DASS-21 is a 21-item inventory comprised of three scales: depression, anxiety, and stress. This measure was specifically designed to maximize differentiation between anxiety, depression, and stress, as these constructs are often highly correlated with one another when measured with other scales (Lovibond & Lovibond, 1995). Additionally, this measure does not include items assessing suicidal ideation. This measure demonstrates acceptable to excellent internal consistency and validity (Antony et al., 1998). In this study, we only used the depression and anxiety scales. Cronbach’s alpha for the depression and anxiety scales were .88 and .84, respectively.

Procedure

Participants completed computerized questionnaires during pregnancy between 8 and 38 gestational weeks (T1) and again between six and eight weeks postpartum (T2). During this assessment, participants completed multiple self-report measures, including the PHQ-9 and DASS-21 which were collected at both T1 (antenatal) and T2 (postpartum).

If a participant reported suicidal ideation on any item in the study, a risk assessment was conducted (Joiner et al., 1999) which included an assessment of lethal means and plans, preparation, and intent to die by suicide. Further, a safety plan was developed that included coping strategies for keeping oneself safe and phone numbers for suicidal crisis (i.e., 911 and National Suicide Prevention Lifeline). These participants were also provided with referral information for a local outpatient therapy clinic. Participants with severe or extreme risk according to the risk assessment would have been guided through an individualized process for urgent assessment at the local hospital. None of the participants in the current study presented with severe or extreme risk. Previous research demonstrates that assessing people for suicide risk does not increase their likelihood of experiencing SI, suicide attempts, or suicide deaths (Blades et al., 2018).

Data Analysis

IBM SPSS Statistics was used for all analyses. First, to account for missing data at the postnatal session due to attrition of 15% (n = 42) between the antenatal and postnatal sessions, multiple imputation was used on the study variables (i.e., the antenatal and postnatal depression, anxiety, and SI variables). SPSS detected that the data showed an arbitrary pattern of missing values, so a Markov chain Monte Carlo (MCMC) method was used for imputation with 5 imputation iterations. The subsequent analyses were derived from a dataset in which missing values for the antenatal SI and postnatal depression, anxiety, and SI scores were imputed.

We started the analysis with descriptive statistics (see Table 1) and Pearson correlations between all variables (see Table 1). Next, a logistic regression model was used to predict postpartum SI at T2. Antenatal anxiety symptoms (T1), antenatal depression symptoms (T1), and antenatal SI (T1) were entered as predictors with the first three predictors entered on the same step. Postpartum SI (T2) was the dependent variable. Finally, we performed a complementary logistic regression model to determine if the effects were still significant after controlling for age and gestational weeks at the antenatal assessment. Throughout analyses, SI was collapsed into a dichotomous score (i.e., absent = 0 versus present =1) with scores above zero operationalized as present.

Table 1.

Descriptive Statistics of All Study Variables at Antenatal (Time 1) and Postnatal Assessments (Time 2)

M SD 1 2 3 4 5 6
1.Depression T1 4.25 5.94 ----
2.Anxiety T1 4.96 5.72 .64*** ----
3.Suicidal ideation T1 0.04 0.21 .55*** .25*** ----
4.Depression T2 3.42 5.92 .29*** .38*** .07 ----
5.Anxiety T2 2.45 5.20 .16† .37** .07 .65*** ----
6.Suicidal ideation T2 0.04 0.19 .19** .26*** .20† .28 .51 ----
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Note.

***

p < .001

**

p < .01

*

p < .05.

†

p < .10. Suicidal ideation was coded as present vs absent.

Results

At the T1 antenatal assessment, 10 out of 276 participants (3.62%) reported SI (i.e., had scores of 1 or higher). At the T2 postnatal assessment, nine out of 234 participants (3.85%) reported SI. Of the 10 participants who endorsed SI at T1, two participants (0.72%) also reported SI at T2, six participants (2.17%) reported no SI at T2, and two participants (0.72%) were lost to follow-up. Of the nine participants who endorsed SI at T2, two participants (0.72%) also reported SI at T1, six participants (2.17%) reported no SI at T1, and one participant (0.36%) did not answer the SI question at T1 (i.e., missing response). 219 participants (79.35%) reported no SI at both assessments and 40 participants (14.49%) reported no SI at T1 and were lost to follow-up or did not respond to the SI question at T2.

As shown in Table 1, antenatal anxiety and depression symptoms at T1 were positively and statistically significantly correlated with T2 postpartum SI. The positive correlation between T1 antenatal SI and postnatal SI was close to statistical significance (r = .16, p = .06).

In our main analysis, we conducted a logistic regression model with T2 postpartum SI (coded present vs absent) as the dependent variable and T1 antenatal anxiety, T1 antenatal depression, and T1 antenatal SI as independent variables. The logistic regression model was significant (𝜒2 (3, 273) = 17.27, p < 0.001) with a Nagelkerke R2 of .15. Higher scores on T1 antenatal anxiety were related to increased postpartum SI at Time 2 (OR = 1.13, 95% CI = [1.02, 1.25], p = .017). Antenatal depression symptoms (OR = 0.97, 95% CI = [0.86, 1.09], p = .63) and antenatal SI at Time 1 (OR = 3.70, 95% CI = [0.35, 38.95], p = .26) were not associated with increases in postpartum SI at T2. Results are depicted in Table 2. The results were consistent when controlling for age and gestational weeks at the antenatal assessment. Antenatal anxiety was the only significant predictor of postpartum SI (OR = 1.13, 95% CI = [1.01, 1.26], p = .032). All other independent variables were non-significant.

Table 2.

Logistic Regression Predicting Suicidal Ideation at Follow-Up (Time 2)

Odds Ratio Lower CI Upper CI p
Anxiety T1 1.13 1.02 1.25 .017
Depression T1 0.97 0.86 1.09 .63
Suicidal ideation T1 3.70 0.35 38.95 .26
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Note.

***

p < .001

**

p < .01

*

p < .05

†

p < .10. Suicidal ideation was coded as present vs absent.

Discussion

The purpose of this longitudinal study was to investigate the relative contribution of anxiety, depression, and SI at the antenatal stage on subsequent postpartum SI. All three antenatal predictors were positively and significantly correlated with postpartum SI. When investigated within the context of logistic regression, antenatal anxiety symptoms outperformed both antenatal SI and depression symptoms in the prediction of postpartum SI. Indeed, when taking both anxiety and depression symptoms into account, antenatal SI and depressive symptoms no longer predicted postpartum SI. These findings indicate that antenatal anxiety likely accounts for postpartum SI variance explained by antenatal SI and depression – as well as unique variance in postpartum SI. Collectively, anxiety symptoms during pregnancy were the best predictor of risk for postpartum SI – even relative to antenatal SI and depressive symptoms.

Our finding that antenatal anxiety and depressive symptoms are both highly correlated with postpartum SI is consistent with previous research indicating a strong relationship between these constructs among antenatal and postpartum women (Bodnar-Deren et al., 2016; Gressier et al., 2016; Patel et al., 2012; Paris et al., 2009; Skouteris et al., 2009). Indeed, research has routinely demonstrated that anxiety and depressive symptoms during the antenatal phase confer risk for postpartum SI (Grigoriadis et al., 2019; Orsolini et al., 2016). Furthermore, identifying antenatal patients who may be at elevated risk of developing postpartum SI could help clinicians treat, reduce, or even prevent SI in the population. This could reduce the burden on mothers and families who are more likely to suffer the deleterious effects associated with postpartum SI.

Furthermore, these findings extend the scope of previous literature, by comparing the relative contribution of antenatal anxiety and depressive symptoms toward postpartum SI when anxiety and depression are considered together. While previous work primarily investigated antenatal anxiety and depression independently of each other, our work takes into account the relative way that they predict postpartum SI. For the first time, our study demonstrated that anxiety can be a stronger predictor than depression. It may contribute to and confer risk for SI among women in the perinatal stage of their pregnancy.

Clinical Implications

There are three possible treatment implications stemming from this work. First, in addition to routinely assessing perinatal patients for depressive symptoms, clinicians should also assess patients for anxiety symptoms. Second, our work demonstrated that both antenatal anxiety and depression symptoms were strongly and positively correlated with postpartum SI. Accordingly, if anxiety or depressive symptoms are present among perinatal women, clinicians should ensure that patients are screened for SI and that any suicide risk among this population is well-managed. As such, screening tools aimed at detecting elevated risk for postpartum SI should assess not only depression but also anxiety symptoms. Third, our results showed the importance of antenatal anxiety symptoms even when considering antenatal depression and SI. Thus, anxiety symptoms might be an efficacious treatment target to reduce SI. Antenatal anxiety symptoms may be more important in the prediction and development of postpartum SI than previously thought. Based on our findings, we would tentatively recommend that clinicians assess for and treat antenatal anxiety, and not just depression. Our findings underscore the need to examine the efficacy of anxiety-related treatments as a way of preventing suicide during antenatal and postpartum stages of pregnancy. Indeed, there is evidence in previous work within community-based samples that reductions in anxiety symptoms were associated with reductions in suicidal ideation (Schmidt et al., 2017). However, this community-based sample likely could not be generalized to the perinatal population.

Research Implications

It is interesting and noteworthy that within this sample anxiety conferred more risk for SI than depression symptoms or even SI itself. This pattern in risk is not evident in broader populations or even other treatment-seeking samples (Franklin et al., 2017). Typically, depression symptoms and SI confer more risk than anxiety symptoms for SI. There may be something unique about the shift from the antenatal to the postpartum period that lends particular insight to the progression toward and the development of SI. Indeed, there are many unique mechanisms involved in the perinatal population that could give fodder to the development of SI. For example, neurological functioning, structures, and systems change between these two-time points (antenatal to postpartum), and this could contribute to the progression from anxiety symptoms to SI.

In perinatal women, there is evidence of change in activities in structures and systems of the brain related to threat perception and anxiety Changes within the amygdala (e.g., Duan et al., 2019; Jones et al., 2017) and HPA axis (e.g., Dickens & Pawluski, 2018) in particular could confer risk from threat perception to fairly abrupt onset of SI. This is consistent with some studies that propose a biological underpinning for SI (Oquendo et al., 2015). Likewise, significant shifts in hormonal composition could contribute to the development of SI. Within perinatal women, there is evidence of intense and rapid changes in the level of estrogen (Mehta et al., 2019), testosterone, and estradiol (Edelstein et al., 2016). It could be that the rapid changes (not necessarily the levels of the hormones themselves) are responsible for at first anxiety and then SI. This is again consistent with literature that points to hormonal imbalances as risk factors for SI (Fu et al., 2022).

Alternatively, specific maladaptive and anxious cognitions particularly evident in perinatal women could again contribute to the rapid development and intensification of SI. For example, perinatal women with elevated anxiety symptoms have routinely reported intense, profound, and nearly all-consuming worries related to the health, welfare, future, and even the life of their child. These thoughts of hopelessness, lack of ability to competently manage threat to their children, and the fear of inevitable and impending danger may lead quickly to SI. This is consistent with the theoretical underpinnings of the Hopelessness Theory (Beck, 1976), Interpersonal Theory (Van Orden et al., 2010), and the Integrated Motivational-Volitional Theory (O’Connor & Kirtley, 2018) that propose that hopelessness, perceived burdensomeness (i.e., lack of competence), and entrapment/defeat lead to SI. Finally, the financial, social, occupational, and physical/health stressors that accompany the birth of a child are clearly documented in the literature (Ayers et al., 2019). The level and scope of stressors that accompany the birth of a child likely are among the most intense that American women experience in their lifetimes. The widespread and rapid experience of stressful life events in particular may lead patients from anxiety to SI. All these possibilities warrant further investigation.

Limitations

In this study, SI was measured using a single binary item. This fails to fully measure the dimensional and multifaceted nature of SI. Recent research has demonstrated mixed efficacy, reliability, and utility in measuring and studying suicidality with one item. For example, Hom et al. (2016) demonstrated strong efficacy with a single-item measure of suicide attempts. However, Na et al. (2018) found that a single-item SI measure was not an effective predictor of future SI. Furthermore, with SI via a single-item measure, resolution and nuance are lessened, resulting in some loss of granularity in the particular experiences of SI. Indeed, this could indicate a skewed perception of SI in the present sample. However, the single-item assessment of SI is discrete enough to determine the presence versus absence of SI, which is useful in answering questions like the ones investigated in this project. While the single-item assessment of SI could not measure the entire spectrum of the nuanced nature of SI, the validity of single-item screenings is widely supported. For example, Smith et al. (2009) found robust support in detecting patients in primary care settings who met the criteria for unhealthy alcohol consumption using just a single-item measure.

Another limitation of our study is the relatively low base rate of SI reported during the postnatal period. While the base rate of SI within the entire postnatal US population is estimated to be approximately 7% (Xiao et al., 2022), roughly half of that percentage (i.e., 3.85%) endorsed SI in the postnatal period within our sample. This relatively low base rate may have impacted results, perhaps by suggesting that no relationship exists between perinatal psychopathology (e.g., perinatal SI) and postnatal SI, when in fact a relationship does exist. This low base rate of SI within our sample could also suggest that some high risk/more severe patients with significant comorbidities of SI (e.g. substance use disorder, homelessness, chronic illness, chronic pain) were not included in this work. While the researchers in the present study did not provide any strategies to mitigate the low base rate of SI in the postnatal measurement, future research should seek to investigate the link between perinatal and postnatal psychopathology in a sample of postnatal women with representative prevalence of SI (i.e., a sample wherein approximately 7% endorse SI within the postnatal period) including postnatal women with comorbidities of SI (e.g., substance use disorders, homelessness, etc.).

Beyond the limitations of using a single-item assessment of SI, data from the current study were constrained to women in a single clinic in the southeastern United States. Therefore, findings may not hold true in samples from more rural or more urban parts of the country. Likewise, this sample, as well as most of the previous research within the field of perinatal mental health, has taken place in the context of inclusion criteria of being with perinatal women (i.e., respondents are only included if they have a gender identity as “woman”). This inclusion criteria thus excludes people who were assigned the female sex at birth but identify as another gender (e.g., man, non-binary, etc.). This leaves considerable concern regarding the perinatal period in people who have a gender identity other than women. It is likely, but unstudied, that people who identify as genders other than “woman” will have elevated risk during the perinatal period, even compared to perinatal women, based on the interaction between the elevated risk which emerges during this vulnerable period with elevated risk commonly associated with identifying as a member of gender minorities (Leonard et al., 2022; Obedin-Maliver et al., 2016).

Conclusion

Antenatal anxiety symptoms and depression symptoms have been shown to confer risk for postpartum SI. Our longitudinal study demonstrated that antenatal anxiety symptoms, more so than antenatal depression symptoms and SI, confer risk for postpartum SI. Indeed, when studied simultaneously, antenatal depression symptoms and SI no longer conferred risk for postpartum SI when antenatal anxiety symptoms were included in the model. Our findings indicate that antenatal anxiety symptoms are a promising target for treatment to reduce and prevent postpartum SI.

Acknowledgments:

Authors have no acknowledgments on the present paper.

We would like to thank Bill Hambsh, David O’Bryan, Erin Ryals, and the staff at North Florida Women’s Care for their support with subject recruitment.

Funding:

This work was supported by the following grants: NIMH R21MH116481, NIMH F31MH125624, DOD W81XWH-16-2-0003, VA 3Q072019C

Footnotes

Disclosures

Data can be made available upon reasonable request to Dr. Elizabeth Mulligan, mulligan@psy.fsu.edu.

Declarations of interest: None.

Conflict of Interest

Authors have no conflicts of interest.

Data sharing:

Data are available upon request from Liz Mulligan, PhD mulligan@psy.fsu.edu.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data are available upon request from Liz Mulligan, PhD mulligan@psy.fsu.edu.

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