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. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: J Affect Disord. 2021 Jul 19;294:701–706. doi: 10.1016/j.jad.2021.07.009

High Worry in Pregnancy Predicts Postpartum Depression

Lauren M Osborne 2,3,*, Kristin Voegtline 1, Lindsay R Standeven 2, Bridget Sundel 2, Meeta Pangtey 2, Liisa Hantsoo 2, Jennifer L Payne 2,3
PMCID: PMC8442474  NIHMSID: NIHMS1731234  PMID: 34343928

Abstract

Background.

Anxiety in pregnancy is one of the strongest risk factors for postpartum depression (PPD), and high worry is a hallmark of many anxiety disorders. We sought to determine whether the Penn State Worry Questionnaire (PSWQ), designed for the general population, could identify high worry in pregnancy and predict the development of PPD symptoms (PPDS).

Methods.

We followed women (N=295) with and without mood and anxiety disorders across pregnancy and up to 6 months postpartum. Diagnoses were confirmed by SCID and by an experienced perinatal psychiatrist, and we administered the PSWQ and the Edinburgh Postnatal Depression Scale (EPDS) at up to 6 time points. We determined the trajectory of worry across time and its relationship to PPDS.

Results.

Women with a history or current diagnosis of major depressive disorder (MDD) or generalized anxiety disorder (GAD) were more likely to experience high antenatal worry (defined as PSWQ >60), p < 0.004 for MDD and <0.001 for all others. High antenatal worry was the only significant predictor of PPDS, with an OR of 3.91 (95% CI 1.44–10.65); neither psychiatric diagnosis nor elevated antenatal depressive symptoms was significantly associated with PPDS in a multivariate model.

Limitations.

Our study used self-report measures in a largely heterogeneous population, which may limit the generalizability of our results.

Conclusions.

The PSWQ may be a useful clinical tool in pregnancy. High worry is a strong predictor of PPDS, and is a better predictor of PPDS than psychiatric diagnosis or elevated antenatal depressive symptoms in this population.

Keywords: worry, anxiety, pregnancy, postpartum, depression

Introduction

Postpartum depression (PPD) is a serious illness affecting 15–20% of women in the developed world, with higher rates in low and middle-income countries and in certain subgroups (Bauman et al., 2020; Yonkers et al., 2011). It is associated with significant morbidity and mortality, with suicide a leading cause of death in the first year postpartum, and can have long-term effects on both the women who suffer from it and on their children and families (Shadigian and Bauer, 2005; Yonkers et al., 2011). Psychosocial risk factors for PPD include younger age, low social support and education, personality style, and prior history of a mood disorder (Hutchens and Kearney, 2020). One of the strongest risk factors is anxiety during pregnancy, which is more common than depression (Adewuya et al., 2006; Brunton et al., 2015; Dennis et al., 2017; Gaynes et al., 2005; Grigoriadis et al., 2011; Schofield et al., 2014; Waqas et al., 2015). Not all studies have disentangled antenatal anxiety from antenatal depression, and many different measurement tools have been used; nevertheless, numerous studies have found associations between, for example, antenatal generalized anxiety disorder and subsequent PPD (Coelho et al., 2011); antenatal anxiety as measured by the Brief Measure of Worry Severity and subsequent PPD (Austin et al., 2007); and any antenatal anxiety disorder and subsequent PPD (Sutter-Dallay et al., 2004). A recent systematic review and meta-analysis found that antenatal anxiety was significantly associated with postpartum depression, regardless of whether or not the studies controlled for antenatal depression, with odds ratios ranging from 2.45 to 4.42, depending on the timing of PPD assessment (Grigoriadis et al., 2019).

Anxiety disorders in pregnancy can go undiagnosed (Misri et al., 2015). Women can be reluctant to admit their symptoms during what they think should be a happy time (Meadows-Fernandez, 2018). Physical symptoms of anxiety, such as tension and insomnia, may be conflated with symptoms of pregnancy, and distinguishing normal pregnancy concerns from high worry can often be difficult, for both women and clinicians (Goodman et al., 2014; Misri et al., 2015). Many women present only to an obstetric provider (and not a mental health provider) during pregnancy (Bhat et al., 2017), so do not come into contact with professionals skilled at diagnosing mental health disorders. In addition, while some women have diagnosable anxiety disorders during pregnancy, many others report serious symptoms or perceive the presence of a disorder but do not meet criteria. In one study of women in a perinatal day hospital, 63% of women endorsed having generalized anxiety on intake, but fewer than 2% actually met criteria – indicating that some women perceive significant impairment from anxiety symptoms that do not reach the level of any one anxiety disorder (Schofield et al., 2014).

An obvious, if imperfect, solution to that difficulty is the use of screening tools. While screening for depression during pregnancy is now recommended by the US Preventive Services Task Force, there is no such recommendation for anxiety – nor is there a single, commonly used screening tool specific to the perinatal period (as the Edinburgh Postnatal Depression Scale (EPDS) is for depression) (Kozinszky and Dudas, 2015). Many existing scales (such as the State-Trait Anxiety Inventory (STAI) (Bieling et al., 1998); the Generalized Anxiety Disorder 7-item scale (GAD-7) (Löwe et al., 2008); and the Hospital Anxiety and Depression Scale (HADS-A) (Zigmond and Snaith, 1983) were designed for the general population. While they have all been used in pregnancy (Hepp et al., 2016; Hundley et al., 1998; Mizuno et al., 2017; Osborne et al., 2019; Schubert et al., 2017; Simpson et al., 2014; Sinesi et al., 2019; Zhong et al., 2015), that use may be problematic, as somatic and sleep symptoms are common in pregnancy and may be mistaken for symptoms of anxiety (Sinesi et al., 2019). Pregnancy-specific scales are either extremely brief (the anxiety subscale of the Edinburgh Postnatal Depression Scale (EPDS-A) (Cox et al., 1987) or focused on anxiety about the pregnancy rather than anxiety during the pregnancy (Pregnancy Related Thoughts (PRT) (Rini et al., 1999) and the Pregnancy Related Anxiety Questionnaire (PRAQ) (Huizink et al., 2002). The Perinatal Anxiety Screening Scale (PASS), a more recent addition, covers both pregnancy-specific and more general symptoms of anxiety (Somerville et al., 2014), but relatively few studies have been published using it thus far (Viswasam et al., 2020).

The scales listed above cover various constructs of anxiety, and it may be useful to consider instead scales that focus especially on high worry, a hallmark of many anxiety disorders (Starcevic et al., 2007). While worry can be an adaptive trait (helping people to prepare for negative events), an ability to control worry is the main distinguishing feature between such adaptive worry and excessive high worry. Worry has been identified as a key component of anxiety in pregnant and postpartum women (Mourady et al., 2017; Signal et al., 2017), yet there is no one standard way of measuring worry in this period. A recent systematic review concluded that the construct of worry is psychometrically robust, taps into a core component of perinatal anxiety, and has strong predictive validity for postpartum depression (Sinesi et al., 2019) – so focusing on worry alone may help us to tap into a common source of distress in pregnancy and a potential predictor of PPD.

Several scales have been used to measure worry during the perinatal period, including the Cambridge Worry Scale (Carmona Monge et al., 2012; Gourounti et al., 2012; Green et al., 2003; Gunay and Gul, 2015; Mortazavi and Akaberi, 2016; Ohman et al., 2003; Petersen et al., 2009) and the Brief Measure of Worry Severity (Austin et al., 2007; Gladstone et al., 2005). Our group has recently reviewed the use of these scales in the context of examining the factor structure, validity, and reliability of the Penn State Worry Questionnaire (PSWQ) (Meyer et al., 1990) when used in the perinatal population (Voegtline K, 2021). We found good construct and criterion validity for the PSWQ across the peripartum, and therefore sought to examine in the present study whether the PSWQ, when given antenatally, could be used to predict the development of PPD symptoms.

Methods

Participants

This was a prospective study conducted at The Johns Hopkins University School of Medicine in Baltimore, Maryland, USA. The study was approved by the Institutional Review Board of The Johns Hopkins University, and all subjects gave informed consent. The analysis reported on here is a sub-study (N=295) from a larger ongoing prospective observational study, and includes all participants who had completed the study by the time our university temporarily closed clinical research operations in the face of the COVID-19 pandemic (including some lost to follow up). Because participants could enroll at any point in pregnancy, and because some enrolled participants missed one or more visits due to the nature of the longitudinal protocol, sample size varies across time points, as seen in Table 1. The ongoing parent study is recruiting both women with pre-existing mood and anxiety disorders and healthy controls for a study examining biological and psychological aspects of mood and anxiety symptoms across the peripartum, with approximately 50% of participants having a psychiatric disorder and 50% being healthy controls. Women are recruited through messaging in the medical record, flyers in the hospital, direct approach in obstetric clinics, and advertising in social and print media, with the majority of participants coming through social media. Prior history of mood or anxiety disorder and current diagnoses were determined by a thorough psychiatric interview conducted by an experienced perinatal psychiatrist, using DSM-IV criteria, and confirmed with a Structured Clinical Interview for DSM-IV diagnoses (SCID-IV) conducted by a trained research assistant. Research assistants were trained by the study investigators, and each research assistant observed 5 SCID administrations by a more experienced staff member prior to beginning. In addition, the first 5 SCIDs administered by each research assistant were observed by a more experienced rater. The SCID-IV was completed in its entirety for all participants, so participants were assessed for all mood disorders (including depressive and bipolar disorders) and for all other Axis I psychiatric disorders. When SCID and psychiatrist diagnosis disagreed, the participant was discussed with the research team, including 3 additional perinatal psychiatrists, and a consensus diagnosis was reached. This was a naturalistic study; participants already engaged in mental health treatment continued with their treating providers.

Table 1.

Demographic and Clinical Characteristics (n=295)

All (n=295) Average Antenatal Worry (n= 219) High Antenatal Worry (n=71)
N % N % N % p value
Age .259
 20–24 8 2.8% 6 2.8% 2 2.9%
 25–29 63 21.7% 50 23.0% 13 18.8%
 30–34 128 44.1% 100 46.1% 24 34.8%
 35–39 74 25.5% 49 22.6% 25 36.2%
 40–44 15 5.2% 11 5.1% 4 5.8%
 45 or greater 2 0.7% 1 0.5% 1 1.5%
Race .878
 American Indian 2 0.7% 2 0.9% 0 0.0%
 Asian 17 5.8% 12 5.5% 4 5.6%
 Black 42 14.3% 30 13.7% 11 15.5%
 Other 9 3.1% 6 2.7% 3 4.2%
 White 223 76.1% 169 77.2% 53 74.7%
Education .159
 ≤ Some college 46 16.0% 30 14.1% 15 21.1%
 ≥ Bachelor’s degree 241 84.0% 183 85.9% 56 78.9%
Marital Status .093
 Single 28 9.6% 18 8.3% 10 14.1%
 Married/Relationship 263 90.4% 199 91.8% 61 85.9%
Employed 225 79.0% 170 79.8% 52 75.4% .433
History of Mood Disorder 179 63.0% 121 56.5% 57 83.8% <.001
History of Anxiety Disorder 114 40.3% 66 31.0% 47 69.1% <.001
Diagnosis
 MDD 149 50.5% 102 46.6% 47 66.2% .004
 GAD 68 23.1% 33 15.1% 35 49.3% <.001
Antenatal Medication Use 66 23.3% 39 18.1% 27 39.7% <.001
Parity .068
 Primiparous 143 51.8% 93 44.7% 38 57.6%
 Multiparous 133 48.2% 115 55.3% 28 42.4%
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Note. Five women from the total sample were missing PSWQ worry data during the antenatal period and are not classified into either worry group (N=290). Missing data for selected demographic and clinical variables ranged from 0 to 6%; thus, sample subtotals for individual characteristics across worry groups ranged from 274 to 290.

Study Visits

Participants were seen for study visits at each trimester (at 11–14 weeks (T1), 24–26 weeks (T2), and 33–34 weeks (T3)) and at 2 weeks, 6 weeks, 3 months, and 6 months postpartum. At the first study visit, participants completed the SCID and psychiatric interview and information was collected about demographics, education, employment status, history of childhood trauma, and personal and family medical history. At each study visit, participants provided information about medication use and completed the EPDS (Cox et al., 1987) for depressive symptoms and the PSWQ (Meyer et al., 1990) for worry, as part of a comprehensive series of psychological scales. We did not collect information about behavioral treatments such as psychotherapy. At each study visit, participants also underwent a blood draw for biological factors (not included in this analysis).

Details of Measurement Tools

Categories of antenatal worry were constructed from PSWQ measurement across the three trimesters, averaged across all visits. High antenatal worry was defined as a mean PSWQ score in the top quartile (i.e., greater than or equal to 60) across pregnancy; average antenatal worry was defined as the remainder with a mean PSWQ score in the bottom three quartiles (i.e., less than 60). We chose 60 as the cutoff score both because it represented the top quartile and based on previous literature showing that cutoff scores on this instrument to optimize sensitivity and specificity have ranged from 54 to 65 (Fresco et al., 2003; Goldfinger et al., 2019; Salzer et al., 2009). Elevated postpartum depressive symptoms (PPDS) were defined as a score of 13 or higher on the EPDS at any of the four postnatal assessments spanning 6 months postpartum.

Statistical Analysis

Demographic and clinical characteristics were described for the total sample and compared by Pearson’s chi-squared test between subjects who experienced average antenatal worry and subjects who experienced high antenatal worry, and, additionally, between subjects with and without elevated postpartum depressive symptoms. A mixed effect model with a random intercept was used to estimate the difference in PSWQ score trajectory across the antenatal and postnatal assessments by the presence or absence of elevated postpartum depressive symptoms, accounting for within-person correlations over time (i.e., dependency associated with repeated measures data). A multivariate logistic regression model was used to test the relationship between high antenatal worry and elevated postpartum depressive symptoms, with adjustment of relevant demographic and clinical covariates previously identified as significantly associated with postpartum depressive symptoms or high antenatal worry, to address confounding; these covariates included antenatal medication use. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).

Results

Sample demographic and clinical characteristics are presented for the total sample and by antenatal worry group in Table 1. Participants were between 20 and 47 years of age (mean age 32 years) and the majority were Caucasian (76%) and married or in a committed relationship (90%). Eighty-three percent of the sample had a bachelor’s degree or higher level of education. In terms of clinical diagnosis, 70% of women had a history of either a mood or anxiety disorder, and 34% had a history of both. This broke down to 63% of participants with history of a mood disorder (51% major depressive disorder (MDD), 8% bipolar affective disorder (BPAD), and 4% other) and 40% with a history of an anxiety disorder, as determined by an experienced psychiatrist using DSM-IV criteria during a comprehensive psychiatric interview. Of those meeting criteria for a current disorder (32% MDD alone, 5% GAD alone, and 18% both), the vast majority also had a history of the disorder (94% for mood disorder, 92% for anxiety disorder). All anxiety disorders were assessed in the interview concerning history, but no participant met current criteria for any anxiety disorder other than GAD. Very few women had medical complications of pregnancy, so we were unable to assess outcomes separately for such women. No participants met DSM-IV criteria for a personality disorder, and we did not administer any formal measure of personality style.

There were no significant differences between high worriers (antenatal PSWQ score ≥ 60, n=71, 25% of sample) and low/average worriers (antenatal PSWQ score < 60, n= 219, 75% of sample) according to age, race (Caucasian vs. other), education, or employment status (see Table 1). A greater proportion of single women were high worriers compared to partnered women, though this difference was not statistically significant; further evaluation revealed single women had significantly higher PSWQ scores at the 3rd trimester (t (233) = −2.86, p = .005; single, M = 58.7, SD = 16.9, partnered M = 47.2, SD = 14.9). In addition, there was a significant association between high worry and a history of a mood or anxiety disorder as well as current MDD or GAD diagnosis. Overall, 66 women reported psychiatric medication use at any point during pregnancy. The vast majority of these medications were anti-depressants. High worry was related to increased antenatal medication use; approximately 40% of high worriers used psychiatric medications during one or more trimesters in the antenatal period, compared to 18% of average worriers. First-time mothers had significantly lower worry scores than multiparous women at every time point (t range = 2.19 to 3.25, ps <.05), with the exception of a trend at 3 months postpartum (t (165) = 1.86, p = .07), and were less likely to be high worriers.

Women with postpartum depressive symptoms (PPDS, defined as ≥ 13 on the EPDS at any postpartum visit, n=44, 20% of sample of 224 with postnatal EPDS data ) were significantly more likely to have been high worriers in pregnancy; about 41% of high antenatal worriers had elevated postpartum depressive symptoms, compared to 13% of average to low antenatal worriers (X2 (1, 223) = 19.86, p < .0001). Figure 1 shows raw PSWQ average scores of 56, 56, and 59 (T1, T2, and T3, respectively) for those who would go on to have PPDS and average scores on the PSWQ of 43, 45, and 45 for those who did not go on to have PPDS. A mixed model accounting for dependency of repeated measurement within women showed the difference in antenatal PSWQ scores by PPDS was significant for each assessment point (T1, β = 11.86, SE = 2.97, t = 4.00, p < .0001; T2, β = 12.17, SE = 2.57, t = 4.73, p < .0001; T3, β = 13.87, SE = 2.47, t = 5.62, p < .0001).

Figure 1.

Figure 1.

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Mean Penn State Worry Questionnaire Score across the three trimesters of pregnancy and from two weeks through six months postpartum by elevated postpartum depressive symptoms, defined as a score ≥ 13 on the Edinburgh Postnatal Depression Scale (EPDS). Unadjusted worry scores were significantly higher in the antenatal period (and postpartum) for women who would later have elevated EPDS postpartum, a risk factor for clinical diagnosis of postpartum depression.

We next looked at associations between PPDS and our baseline demographic and clinical characteristics. Women who developed elevated postpartum depressive symptoms had lower levels of education (X2 (1, 223) = 15.45, p = .009) and were more likely to have a history of a mood (X2 (1, 220) = 17.56, p < .0001) or anxiety disorder (X2 (1, 220) = 11.50, p = .001) than those who did not develop elevated PPDS. Women who developed elevated PPDS were more likely to have a current GAD diagnosis at baseline (X2 (1, 223) = 10.25, p = .001), with 41% of those who went on to elevated PPDS meeting baseline criteria for GAD, but only 18% of those without elevated PPDS meeting criteria for GAD. Finally, women who developed elevated PPDS were also more likely to be using psychiatric medications at baseline ((X2 (1, 218) = 7.26, p = .007)). There were no differences between women who developed elevated PPDS and those who did not in age, race, employment, partner status, parity, or, somewhat surprisingly, current MDD diagnosis at baseline.

We next ran a multivariate logistic regression model to determine predictors of elevated postpartum depressive symptoms, including high worry along with relevant covariates (see Table 2, Figure 2). We included only current diagnosis of MDD and GAD and not history of mood or anxiety disorder in the model, due to collinearity. High education was protective at a trend level, with an OR of 0.33 (95% CI 0.10–1.09) for those with a bachelor’s degree or above compared to those with lower levels of education. Participants with current psychiatric diagnoses carried somewhat higher odds ratios for developing PPDS (1.30 and 2.19 for MDD and GAD, respectively), as did those with elevated antenatal depressive symptoms (OR 2.88 for EPDS ≥ 13), but none of these relationships reached statistical significance. High antenatal worry (defined as a PSWQ >60), however, was a significant predictor of PPDS, with an OR of 3.91 (95% CI 1.44–10.65)).

Table 2.

Multivariate logistic regression predicting elevated postpartum depressive symptoms including average prenatal EPDS score of 13 or greater

95% C.I.
Risk factor B SE Wald X2 OR Lower Upper
Maternal education a
  Bachelor’s degree or higher −1.10 0.60 3.30 0.33 0.10 1.09
 
Single −2.04 1.30 2.46 0.13 0.01 1.66
 
Major depressive disorder 0.26 0.49 0.28 1.30 0.50 3.38
 
Generalized anxiety disorder 0.79 0.49 2.54 2.19 0.83 5.76
 
Medication use 0.28 0.52 0.29 1.32 0.48 3.65
 
Elevated antenatal depressive symptoms 1.06 0.74 2.02 2.88 0.67 12.39
 
Elevated antenatal worry 1.36 0.51 7.11 3.91** 1.44 10.65
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a

Note. Reference group collapses high school, some college, and associate’s degree education levels.

**

p < .01

Figure 2.

Figure 2.

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Adjusted odds ratios and 95% Wald confidence intervals predicting postpartum depressive symptoms. High antenatal worry indexed by the Penn State Worry Questionnaire significantly increased likelihood of elevated (EPDS >13) depressive symptoms in the first six months postpartum.

Discussion

Our findings indicate that “high worriers” had a nearly four-fold greater likelihood of developing PPDS than women with low to average worry in pregnancy. The magnitude of this effect is equivalent to that identified for antenatal depression in the much larger and more representative study by Milgrom and colleagues (Milgrom et al., 2008). In our study, high worry in pregnancy was a better predictor of the development of significant postpartum depressive symptoms than either a current psychiatric diagnosis (major depressive disorder or generalized anxiety disorder), the presence of elevated antenatal depressive symptoms, or the use of psychiatric medications in the index pregnancy. There were no demographic factors significantly associated with the development of postpartum depressive symptoms.

There is a considerable literature finding that antenatal depression is one of the strongest risk factors for postpartum depression (Ayoub et al., 2020; Guintivano et al., 2018; Hutchens and Kearney, 2020; Milgrom et al., 2008; Norhayati et al., 2015; Zhao and Zhang, 2020). As many of these studies were larger and more representative than ours, it is possible that our finding that worry predicted PPDS better than did antenatal depressive symptoms may be a result of the sample size, and/or our definition of antenatal depressive symptoms. We did find an elevated odds ratio for PPDS in women with antenatal depressive symptoms, and it is conceivable that this relationship would have reached statistical significance in a larger sample, or if we had measured milder antenatal depressive symptoms rather than using the strict cutoff of 13 on the EPDS. The fact that worry was more predictive than depressive symptoms may also have to do with the population we studied. The majority of our participants had treated psychiatric illness, and nearly all were white and well-educated; worry may be particularly relevant to this population.

Our study has some limitations. It is a substudy from a larger ongoing observational cohort, and we did not conduct a power analysis beforehand to determine whether our sample size was adequate to answer our research question. The psychological scales administered are self-report, and come with all the disadvantages of such measures. We did not include any measure of personality style, so were not able to assess to what extent personality style might be related to our findings on the PSWQ. We did not have a measure of clinician-diagnosed depression in the postpartum, so our findings apply to symptoms of PPD rather than the diagnosed disorder. In addition, we included in our PPDS group women who had an elevated EPDS at any point postpartum; it is therefore possible that we have included some women with transient baby blues symptoms captured at the two-week point. Our sample of mood-disordered women included women with both MDD and BPAD; because the vast majority had MDD, we were unable to run separate analyses by particular diagnosis. The largely homogenous population (mostly Caucasian and highly educated) makes it difficult to generalize our findings to other populations.

Nevertheless, our findings add to the current literature. Antenatal depression and anxiety are routinely identified as among the strongest risk factors for the development of PPD, but in our sample the symptom of worry, which may cut across both diagnoses, was a stronger risk factor for PPDS than either diagnosis or elevated depressive symptoms. As work from the international Postpartum Depression: Action Toward Causes and Treatment Consortium (PACT) has indicated, there are distinct clinical phenotypes of PPD, with three of the five identified phenotypes having anxiety as a major component (Putnam et al., 2017). This fact, along with our work here, may indicate that a focus on the construct of worry may help us to identify women at risk. This, in turn, may help to lead us to a precision medicine approach to perinatal mental illness. Psychotherapeutic techniques specifically targeting worry already exist (Kross et al., 2017; Lenze et al., 2014; Roch-Gagne and Talbot, 2019), and a focus on worry may help us to develop other novel treatments to help these vulnerable patients.

Highlights.

  • Antenatal anxiety is a risk factor for postpartum depressive symptoms (PPDS).

  • Worry is a frequent component of antenatal anxiety but is not always measured.

  • We examined whether antenatal worry (using the Penn State Worry Questionnaire (PSWQ)) predicted PPDS.

  • High antenatal worry (PSWQ>60) strongly predicted PPDS (OR 3.91).

  • The PSWQ may be a useful tool to predict the development of PPDS.

Acknowledgments

The authors wish to acknowledge the assistance of Samantha Meilman, who manages the research database, and of Molly O’Rourke, research assistant, and Courtney Erdly, research coordinator.

Funding Statement

This study was funded by the National Institute of Mental Health, NIMH K23 MH110607–01A1 (PI: Osborne) and NIMH R01 MH112704 (PI: Payne), by the Brain and Behavior Foundation Early Career Investigator Award, and by the Doris Duke Foundation Early Clinician Investigator Award.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflict of Interest Statement

Dr. Payne reports personal fees from Janssen Pharmaceuticals, grants and personal fees from Sage Therapeutics, personal fees from Abbott Pharmaceuticals, outside the submitted work; she also has a patent Epigenetic Biomarkers of Postpartum Depression issued. All other authors report that they have no conflicts of interest to declare.

Data Availability Statement:

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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