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. Author manuscript; available in PMC: 2022 Aug 9.
Published in final edited form as: Stress Health. 2021 Oct 15;38(3):610–614. doi: 10.1002/smi.3100

The role of prenatal posttraumatic stress symptoms among trauma exposed women in predicting postpartum depression

Rebecca Grekin 1, Emily B K Thomas 1, Michelle L Miller 1,2, Michael W O’Hara 1
PMCID: PMC8986883  NIHMSID: NIHMS1750296  PMID: 34617661

Abstract

Research suggests that a history of trauma and prenatal posttraumatic stress symptoms (PTSS) are predictive of postpartum depression (PPD). Pregnant women at risk for PPD are often identified through depression symptom measures, while PTSS also may help to identify those at increased risk. Women who do not endorse depressive symptoms, though experience PTSS, may be missed when screening is exclusively based on depressive symptoms. The current study aimed to determine if prenatal PTSS were associated with PPD at 4- and 12-weeks postpartum in trauma-exposed women. Pregnant women (N=236) in their third trimester were assessed for depression and PTSS at pregnancy, 4 and 12 weeks postpartum. Traumatic life events were assessed during pregnancy. Hierarchical regression analyses examined predictors of PPD, including history of depression, number of past traumas, and symptoms from the PTSD Checklist short-form (PCL-6). At 4 and 12 weeks postpartum, history of trauma and depression did not predict depressive symptoms, however, irritability and unwanted intrusive memories of trauma were predictive of increased depressive symptoms. Prenatal irritability and unwanted memories may be predictive of elevated PPD symptoms. Future research should examine whether these symptoms represent increased risk of postpartum depressive symptoms to improve screening, prevention, and treatment efforts.

Keywords: postpartum depression, trauma, perinatal posttraumatic stress

Introduction

Postpartum depression (PPD) is prevalent, impactful on mothers and their families, and a costly public health issue (Kroska & Stowe, 2020). Therefore, it is important to accurately identify women who may be at increased risk for developing PPD for the purposes of prevention, early detection, and treatment (Freeman, 2019). Past PPD diagnosis, as well as depressive symptoms during pregnancy, are two of the most robust risk factors for developing future PPD (O’Hara & Mc Cabe, 2013). As a consequence, providers often rely on routine depression screening measures like the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire-9 (PHQ-9) to identify women at risk for PPD.

However, recent research suggests that other factors such as a history of trauma and posttraumatic stress disorder (PTSD) confer risk for developing PPD (Guintivano et al., 2018). A vast majority of women experience at least one lifetime traumatic event, with epidemiological studies estimating that about 73% of women in the general population have been exposed to a traumatic event (Grella et al., 2013). Moreover, women with a history of trauma present with a wide range of symptoms during pregnancy that are not identified through typical depression screeners (Freeman, 2019) and may be missed when relying exclusively on current depressive symptoms to determine risk. Unfortunately, history of trauma and PTSD are challenging to assess in an efficient manner (Guintivano et al., 2018) and are not routinely examined, which limits not only our ability to identify at-risk women, but also to provide referrals and treatment to women in need (Powers et al., 2020). Therefore, it is imperative to determine how we can better capture symptom profiles in women at risk for PPD that may be missed with typical depression screenings.

The current study aimed to determine if traumatic stress symptoms measured during pregnancy using the short-form Posttraumatic Stress Checklist (PCL) were associated with PPD at 4- and 12-weeks postpartum among a community sample of trauma-exposed women. To our knowledge, research has not investigated the associations longitudinally between PTSD symptoms during pregnancy and PPD. However, existing literature both in perinatal samples (Seng et al., 2010) and the general population of trauma-exposed adults (Contractor et al., 2018) regarding symptom profiles of PTSD and associations with concurrent depression point to posttraumatic symptoms including irritability, difficulty concentrating, and unwanted memories as being commonly endorsed and significantly associated with depression. Therefore, we hypothesized that irritability, difficulty concentrating, and unwanted memories would be significantly associated PPD in a community sample of trauma-exposed pregnant women.

Methods

Participants

The current sample was drawn from a larger longitudinal study (Grekin et al., 2020). Participants were 230 pregnant women in their third trimester who received prenatal care at a large midwestern hospital. All participants included in this analysis endorsed at least one traumatic event. Participants were primarily White (93.4%), non-Hispanic (95.2%), highly educated (M = 16.13 years of education, SD = 4.32), high-income (median of $60,000-69,999), and married or cohabitating (87.4%). See Table 1 for further characteristics of the sample.

Table 1.

Descriptive characteristics of the sample and correlations

M(SD) 1 2 3 4 5
1. Age 31.71 (4.80)
2. Years of education 16.13 (4.32) 0.38***
3. Depression, pregnancy 36.07 (10.03) −0.22** −0.17*
4. PCL-6, pregnancy 3.28 (3.64) −0.10 −0.12 0.67***
5. Depression, 4-weeks postpartum 35.03 (10.0) −0.15 −0.03 0.65*** 0.42***
6. Depression, 12-weeks postpartum 31.40 (7.17) 0.00 0.04 0.53*** 0.30*** 0.58***
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Note. Depression was measured with the IDAS-II. PCL-6 = Posttraumatic stress disorder checklist-6.

Study Procedures

All study procedures were approved by the University’s Institutional Review Board. The Institute for Clinical and Translational Science identified female patients that were pregnant from April to December 2015. Informational letters were sent to women who were 28 weeks gestation. Women were contacted to determine interest in the study, unless they declined participation. For women interested in participating, research staff confirmed eligibility (28-32 weeks gestation and over 18 years old), and mailed a consent form, which was later reviewed by telephone.

Assessment Procedures

During the course of the study, women completed online assessments and diagnostic interviews during the third trimester (starting at 28 weeks), and at 4- and 12-weeks postpartum. REDCap electronic data capture, hosted at the University of Iowa, was used for data collection and management (Research Electronic Data Capture; Harris et al., 2009). REDCap is a secure, web-based application designed to support data capture for research studies.

Measures

Posttraumatic Stress Disorder Checklist-5 (PCL-5;Weathers et al., 2013).

The PCL-5 is a 20-item self-report measure that assesses symptoms over the last month in accordance with the DSM-5 symptom criteria for PTSD. Items are rated on a 5-point Likert-type scale (0=not at all to 4=extremely). The 6 short-form items were used in this analysis to limit the number of variables in the analyses while still using a validated measure of PTSD. Previous research has indicated good internal consistency with the 6-item form and identified the importance of these six symptoms (Lang et al., 2012). The 6 items assess repeated unwanted memories, feeling very upset when reminded of the experience, avoidance, irritability, feeling jumpy or easily started, and difficulty concentrating. High internal consistency was reported in the current study with the 6 items (a = 0.83).

Inventory of Depression and Anxiety Symptoms-General Depression Scale (IDAS-GD; Watson et al., 2007).

The IDAS-GD scale measures depressive symptoms over the past two weeks, with 20 items rated on a 5-point scale (1=not at all to 5=extremely). Coefficient alpha for the current study was good at 4-weeks (a = 0.91) and 12-weeks postpartum (a = 0.86).

Traumatic Life Events Questionnaire (TLEQ; Kubany et al., 2000).

The TLEQ is a self-report measure assessing if and when participants have experienced 23 traumatic life events, including both interpersonal (e.g., physical punishment, sexual abuse) and non-interpersonal (e.g., natural disaster, accident) trauma. Items are categorical (endorsed/denied). The TLEQ was administered during pregnancy only.

Structured Clinical Interview for DSM-5 Disorders (SCID-5; First et al., 2016).

The SCID is a semi-structured interview for assessing DSM-5 diagnoses. Only the Major Depression module was used, which was administered during pregnancy to measure lifetime history and current depression. History of depression was quantified categorically for presence or absence of current or past depression.

Results

At baseline, 246 women completed the self-report questionnaires; 10 women did not complete the SCID at baseline. At 4-weeks postpartum, 39 women did not complete the self-report questionnaires, and at 12-weeks postpartum, 59 women did not complete the questionnaires. Average depressive symptoms at pregnancy (M = 36.07, SD = 10.03), 4-weeks postpartum (M = 35.03, SD = 10.0), and 12-weeks postpartum (M = 31.40, SD = 7.17) were calculated. At baseline, 27.9% of the sample reported a history of or current depressive episode. Most women reported interpersonal trauma (79.1%) and non-interpersonal trauma (70.9%), and over half (53.9%) reported both interpersonal and non-interpersonal trauma.

Hierarchical regression analyses were conducted to examine predictors of postpartum depression, including history of depression and number of past traumas (Step 1) and the 6 items from the short-form PCL (Step 2).

At 4-weeks postpartum (Table 2), the final model accounted for 23% of the variance (R2 = 0.23), and at 12-weeks postpartum 16.8% of the variance in depressive symptoms (R2 = 0.168). In the final model, history of depression was not significantly predictive of depressive symptoms at 4-weeks postpartum (B = 1.69, SE = 1.43, β= 0.09, t = 1.18, p = .24) or 12-weeks postpartum (B = −0.31, SE = 1.29, β = −0.02, t = −0.24, p = .81). The number of past traumatic events did not predict depressive symptoms at 4-weeks postpartum (B = 0.03, SE = 0.33, β = 0.01, t = 0.09, p = .24) or at 12-weeks postpartum (B = −0.02, SE = 0.31, β= −0.01, t = −0.06, p = .95). Item 1 (repeated, disturbing, and unwanted memories of the stressful experience) was significantly predictive of increased postpartum depressive symptoms at 4-weeks postpartum (B = 2.10, SE = 1.04, β = 0.20, t = 2.02, p = 0.045) and at 12-weeks postpartum (B = 2.64, SE = 0.94, β = 0.31, t = 2.80, p = .006). Item 15 (irritable behavior, angry outbursts, or acting aggressively) was significantly predictive of increased depressive symptoms at 4-weeks postpartum (B = 2.90, SE = 0.88, β = 0.29, t = 3.28, p = .001) and at 12-weeks postpartum (B = 2.46, SE = 0.79, β = 0.29, t = 3.11, p = .002). Step 2 significantly added to the final models at 4-weeks (F-change (6, 173) = 5.31, p < .001) and 12-weeks postpartum (F-change (6, 154) = 4.36, p < .001).

Table 2.

Predictors of depression at 4-weeks and 12-weeks postpartum

B SE β t p R2
Outcome: 4-weeks postpartum depressive symptoms
Model 1 .09
History of depression 4.95 1.37 .26 3.61 <.001
Past traumatic events .46 .33 .10 1.37 .17
Model 2 .23
History of depression 1.69 1.43 .09 1.18 .24
Past traumatic events .03 .33 .01 .09 .09
PCL 1 2.10 1.04 .20 2.02 <.05
PCL 4 1.38 .93 .14 1.48 .14
PCL 6 −1.11 .79 −.12 −1.41 .16
PCL 15 2.90 .88 .29 3.28 <.001
PCL 18 .37 1.06 .03 .35 .73
PCL 19 −.73 1.02 −.06 −.72 .47
Outcome: 12-weeks postpartum depressive symptoms
B SE β t p R2
Model 1 .03
History of depression 2.27 1.22 .15 1.86 .06
Past traumatic events .19 .31 .05 .60 .55
Model 2 .17
History of depression −.31 1.29 −.02 −.24 .81
Past traumatic events −.02 .31 −.01 −.06 .95
PCL 1 2.64 .94 .31 2.80 .006
PCL 4 .05 .86 .01 .06 .95
PCL 6 −.62 .77 −.08 −.80 .42
PCL 15 2.46 .79 .29 3.11 .002
PCL 18 .52 .98 .05 .53 .60
PCL 19 −1.48 .99 −.15 −1.50 .14
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Note. n = 181 at 4-weeks postpartum. n = 162 at 12-weeks postpartum. History of depression was assessed with SCID depression module. Past traumatic events were measured by TLEQ and represents total past traumatic events reported. PCL = PTSD Checklist for DSM-5. Item numbers for the short form of the PCL-5 reflect their position in the PCL-5 20-item version. Bolded = significant at p < .05.

Discussion

The current study examined prenatal PTSD symptoms as a predictor of postpartum depressive symptoms in a community sample of trauma-exposed adult women. Prenatal re-experiencing (memories) and irritability (e.g., irritable behavior, angry outbursts, or acting aggressively) were significant predictors of elevated depressive symptoms at both 4- and 12-weeks postpartum. To our knowledge, this is the first study to examine how specific prenatal PTSD symptoms may predict postpartum depressive symptoms in a community sample of adult perinatal women. The prospective nature of the study, as well as the inclusion of both prenatal and postpartum assessments, are strengths of the study. In addition, history of depression was examined by structured diagnostic interview and included as a covariate. All women included in the study reported a history of trauma exposure, but the low prevalence of PTSD in this sample highlights the importance of examining PTSD symptoms among trauma-exposed samples as opposed to PTSD diagnosis alone.

Intrusive memories of trauma exposure predicted increased depressive symptoms. This is consistent with the literature as intrusive memories are one of the most common symptoms of PTSD (Bomyea & Lang, 2016), including among pregnant women (Seng et al., 2010). Additionally, unwanted and intrusive memories, a hallmark symptom of PTSD, have repeatedly been shown to be positively associated with depression in trauma-exposed adults (Mihailova & Jobson, 2018).

Irritability during pregnancy was also a consistent predictor of depressive symptoms throughout the postpartum period. This adds to the growing literature demonstrating that irritability is associated with postpartum depressive symptoms (Williamson et al., 2015). Irritability is often considered a transdiagnostic feature, associated with a range of psychiatric conditions in adults, such as generalized anxiety disorder, bipolar disorder, major depressive disorder, and PTSD (Yager, 2020). This study provides more evidence that prenatal irritability could be an early indicator of a broader mood disturbance rather than reflecting perinatal-specific circumstances (e.g. interrupted sleep; (Kamphuis et al., 2012).

Prenatal irritability significantly predicted elevated postpartum depressive symptoms, even when controlling for two robust predictors of postpartum depression, history of depression and total trauma exposure. While the literature is decisive that a history of depression predicts postpartum depression (Kroska & Stowe, 2020), the relation between trauma exposure and postpartum depressive symptoms is more nuanced (Grekin et al., 2017; Miller et al., 2017). Findings from this study suggest that PTSD symptoms, such as irritability, may be important indicators to assess rather than simply the presence or absence of trauma.

Current screening practices for perinatal women could be improved by screening for trauma as well as irritability to help capture those most at risk. In addition to screening for trauma history, depressive screeners could be modified to include questions on irritability. Some of the most well-used depression screening measures, such as the EPDS and PHQ-9, do not assess for irritability. Patients may find it more normative to disclose irritability on a depressive screening rather than report a history of trauma. Alternatively, perinatal screening could include screening measures that do currently assess irritability. One common screening measure, the Generalized Anxiety Disorder Screener (GAD-7) assesses irritability and could be used in tandem with traditional postpartum depression screening measures. A standard prenatal screen for both trauma history and irritability may allow for women most at risk for postpartum depression to be identified before the potential onset of postpartum depressive symptoms.

The current study was not without limitations. First, the sample was homogenous in terms of white racial identity, moderate to high income levels, and married or partnered relationship status. Additionally, women endorsed low levels of depressive and PTSD symptoms and very few women met criteria for PTSD during pregnancy. Together, these sample characteristics suggest that the results may not be generalizable to a broader population of pregnant women. Future research should aim to explore these questions in a more diverse sample with higher levels of psychiatric symptoms. Finally, the current study did not examine the impact of traumatic childbirth on outcomes. Future research might examine if and how previous experience of traumatic childbirth may alter how PTSS symptoms during pregnancy are related to PPD.

In conclusion, this study suggests that perinatal irritability and the experience of intrusive, unwanted memories may be understudied, robust predictors of elevated postpartum depressive symptoms. Future research should further examine whether irritability and unwanted memories represent an increased risk of postpartum depressive symptoms to improve, screening, prevention and treatment efforts.

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