Anxiety and depressive symptoms in women and men from early pregnancy to 30 months postpartum

JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY, 2017 https://doi.org/10.1080/02646838.2017.1368464 Anxiety and depressive symptoms in women and men from early pregnancy to 30 months postpartum CatarinaCanário‡ and BárbaraFigueiredo School of Psychology, University of Minho, Braga, Portugal ABSTRACT Aims: The aims of this study were to analyse the changes in anxiety and depression symptoms from early pregnancy to 30 months postpartum according to gender and parity. Method: 129 couples (N=258) recruited from an obstetrics unit completed self-report measures of anxiety and depression at each pregnancy trimester, childbirth, 3 and 30 months postpartum. Using multilevel modelling, piecewise dyadic growth curve models were performed, assessing time, gender and parity as predictors of anxiety and depression symptoms. Results: Anxiety and depression symptoms decreased from the first trimester to 3 months postpartum and increased from 3 to 30 months postpartum, returning to the baseline levels in the overall sample. The symptoms were positively correlated within-dyad; in a given time point when a partner reported more symptoms, the other reported more symptoms as well. Changes in anxiety and depression symptoms over time were different according to gender and parity, especially from 3 to 30 months postpartum. Primiparous women revealed low stable symptoms, whereas multiparous women revealed the steepest symptoms increase (in comparison to primiparous men and women and multiparous men). Conclusions: This study corroborates the literature considering that the transition to parenthood can last until the child’s age of 2 or 3 years. Results point out that the risk for anxiety and depression symptoms increasing over the postpartum period is greater for multiparous and lesser for primiparous women. Future studies should explore the factors that contribute to the high risk of symptoms increase over the postpartum period for multiparous women. Screening and intervention should target couples and not only women. Introduction Even though the transition to parenthood is acknowledged to be a normative life transition, because it is expected and experienced by the vast majority of individuals and/or families in the population (Cowan, 1991), it also represents a challenging period, requiring individual and dyadic adjustment to several bio-psychosocial changes. Family distress and adaptation can take place across several interrelated domains, which include the self, the couple and © 2017 Society for Reproductive and Infant Psychology KEYWORDS Anxiety and depression symptoms; pregnancy and postpartum; gender and parity; dyadic growth curve analyses ARTICLE HISTORY Received 14 May 2016 Accepted6 June 2017 CONTACT Catarina Canário [email protected] ‡Current affiliation: Faculty of Psychology and Education Science of the University of Porto Downloaded by [87.103.58.88] at 09:50 15 September 2017 2 C. CANÁRIO AND B. FIGUEIREDO the family (Cowan & Cowan, 2012; Cowan, Cowan, Heming, & Miller, 1991). One of these domains regards the characteristics of each parent, and includes aspects such as self-concept, self-esteem, symptoms of depression and anxiety and emotional distress (Cowan & Cowan, 2012; Cowan et al., 1991). In terms of the sense of self, one of the major challenges for individuals, both women and men, is to cope with the impact of psychological changes (Cowan et al., 1991). As the transition to parenthood can last until the child’s age of 2–3 years (Cowan et al., 1991), it is important to study the symptoms of depression and anxiety in both men and women from pregnancy through the first three years postpartum, due to the fact that these symptoms have been found to significantly affect factors such as the couple’s relationship quality, parent–child interaction and the overall child’s development (e.g. Dubber, Reck, Müller, & Gawlik, 2015; Giallo, Woolhouse, Gartland, Hiscock, & Brown, 2015; Parfitt & Ayers, 2009). The adaptation to this transition is not limited to the first child – it also takes place when a second or third child becomes part of the family. Recent literature suggests that psychological difficulties might exist not only for primiparous women but also for multiparous women (e.g. Dipietro, Costigan, & Sipsma, 2008; Sutter-Dallay, Cosnefroy, Glatigny-Dallay, Verdoux, & Rascle, 2012). Nevertheless, the particular challenges that pregnancy and the postpartum period pose to primiparous and multiparous women and men, both individually and as a dyad, in terms of their depression and anxiety symptoms remain unclear. Anxiety and depression are two different conditions that can either occur independently or coexist (American Psychiatric Association, 2013). The symptoms have frequently been jointly assessed in studies focused on the transition to parenthood, as they have often been found to be comorbid during this period (e.g. Heron, O’Connor, Evans, Golding, & Glover, 2004; Kessler, Keller, & Wittchen, 2001; Wenzel, 2011). Despite the great number of studies addressing anxiety and depression symptoms over pregnancy and the postpartum period, conflicting evidence exists regarding the course of symptoms over these periods. Some studies indicated an increase in women’s and men’s depression symptoms from pregnancy to 12 months postpartum (e.g. Matthey, Barnett, Ungerer, & Waters, 2000), and in men’s depression symptoms from pregnancy to 6 months postpartum (e.g. Paulson & Bazemore, 2010). Other studies revealed the stability of women’s anxiety and depression symptoms over pregnancy and the postpartum period (e.g. Giardinelli et al., 2012; Heron et al., 2004). Recent studies identified a decrease in women’s anxiety symptoms across pregnancy (e.g. Buist, Gotman, & Yonkers, 2011; Matthey & Ross-Hamid, 2012), and a decrease in women’s anxiety and depression symptoms from pregnancy to 24 months postpartum (Dipietro et al., 2008). Further studies reported a decrease in both women’s and men’s anxiety and depression symptoms from pregnancy to 6 months postpartum (Whisman, Davila, & Goodman, 2011). Women’s anxiety and/or depression symptoms during pregnancy and the postpartum period have been studied extensively. Only recently, research has also begun to look at men and determined that 10% of new fathers experience mental health difficulties, in addition to reporting that paternal postnatal depression during the first year postpartum is predicted by parenting distress, marital relationship quality and parenting efficacy (e.g. deMontigny, Girard, Lacharité, Dubeau, & Devault, 2013; Singley & Edwards, 2015). Furthermore, only recently has research started to include both members of the couple as participants, and point out that women’s and men’s postpartum depression symptoms are positively Downloaded by [87.103.58.88] at 09:50 15 September 2017 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY 3 associated (e.g. Don & Mickelson, 2012; Kerstis, Engström, Edlund, & Aarts, 2013; Perren, von Wyl, Bürgin, Simoni, & von Klitzing, 2005). Women were usually found to exhibit higher anxiety and depression symptoms than men at the third pregnancy trimester, childbirth, 3 and 12 months postpartum (Escriba-Aguir & Artazcoz, 2011; Escribe-Aguir, Gonzalez-Galarzo, Barona-Vilar, & Artazcoz, 2008); however, data are somewhat inconsistent regarding gender effects over time. Some studies did not identify gender effects on anxiety and depression symptoms over pregnancy and/or the postpartum period (e.g. Parfitt, Pike, & Ayers, 2013; Perren et al., 2005), while in other studies, anxiety symptoms were found to remain stable for women while decreasing for men from late pregnancy to 12 months postpartum (Keeton, Perry-Jenkins, & Sayer, 2008). Furthermore, in other studies depression symptoms were found to increase until 12 (Keeton et al., 2008) or to decrease until 24 months postpartum (Rholes et al., 2011) in women while remaining stable for men from late pregnancy to 12 and 24 months postpartum. Studies assessing parity differences on anxiety and depression symptoms over pregnancy and the postpartum period are rare and include mostly women (e.g. Di Florio et al., 2014; Melo et al., 2012; Sutter-Dallay et al., 2012). As far as we can ascertain, data on the differences of parity on men’s symptoms over pregnancy and the postpartum period are limited to a single study determining lower psychological symptoms in primiparous men when compared to multiparous men at the third trimester of pregnancy (Condon & Esuvaranathan, 1990). Moreover, results regarding parity effects on anxiety and depression symptoms over pregnancy and the postpartum period are controversial. While some studies found no differences in depression symptoms between primiparous and multiparous women during the puerperium (e.g. Breitkopf et al., 2006; Giardinelli et al., 2012), others reported more anxiety (Zanardo, Gasparetto, Giustardi, & Suppiej, 2009) and depression (Di Florio et al., 2014) symptoms in primiparous women during the puerperium, whereas further studies revealed more depression symptoms in multiparous women during pregnancy (Melo et al., 2012; Sutter-Dallay et al., 2012). Regarding the symptom trajectories, from 6 weeks to 24 months postpartum, Dipietro et al. (2008) found an increase in primiparous women’s anxiety symptoms, and a decrease in multiparous women’s anxiety and depression symptoms. In a couple, both members of the dyad mutually influence each other: one partner affects and is affected by the other partner (Kenny, Kashy, & Cook, 2006). The interdependence between partners refers to this causal influence happening to the members of a couple and has recently been identified for anxiety and/or depression symptoms experienced in situations other than the transition to parenthood (e.g. Chung, Moser, Lennie, & Rayens, 2009; Dekel et al., 2014; Parker, Johnson, & Ketring, 2012). Despite some studies identifying positive correlations between men’s and women’s anxiety and/or depression symptoms over pregnancy and/or the postpartum period, interdependence between partners was usually not considered (e.g. Areias, Kumar, Barros, & Figueiredo, 1996; Dudley, Roy, Kelk, & Bernard, 2001; Keeton et al., 2008). To the best of our knowledge, to date, only two studies have contemplated the interdependence between partners for anxiety and depressive symptoms during pregnancy and the postpartum period. Anxiety symptoms were found to be positively correlated within-dyad, as opposed to depression symptoms that were found to be negatively correlated within-dyad (Don, Chong, Biehle, & Mickelson, 2014; Rholes et al., 2011). Given that few studies focused on anxiety or depression symptoms over the transition to parenthood included several assessment waves over pregnancy and the postpartum period, and that fewer studies considered gender, parity and within-dyad interdependence, Downloaded by [87.103.58.88] at 09:50 15 September 2017 4 C. CANÁRIO AND B. FIGUEIREDO the purpose of the present study was to analyse the individual and dyadic trajectories of men’s and women’s anxiety and depression symptoms, using dyadic growth curve models: (a) from the first trimester to 30 months postpartum, (b) assessing gender and parity differences and effects, and (c) examining the interdependence between partners’ symptoms. Method Participants This study followed a sample of couples surveyed from the first trimester until 30 months postpartum. Three hundred and fifty-seven pregnant women were invited to integrate the study in an Obstetrics Unit at their first pregnancy trimester appointment. Even though 300 women agreed to participate, only a sample of 260 couples was recruited, corresponding to the situations where both the pregnant women and her partner agreed to participate. Most of these participants were Portuguese (91.4%), aged between 20 and 39 years old (85.9%), from low or medium–low socioeconomic levels (57.4%), had nine or more years of education (67.2%), were employed (80.4%), married or cohabiting (88.4%) and primiparous (55%), as presented in Table 1. The study had six assessment waves, at the first (between weeks 8 and 14), second (between weeks 20 and 24) and third ((between weeks 30 and 34) pregnancy trimester, childbirth (between days 1 and 3), 3 (between weeks 10 and 14) and 30 months (between months 24 and 36). A total of 215 couples (n = 430, 82.7%) completed all assessment waves until 3 months postpartum, and a total of 129 couples completed all assessment waves until 30 months postpartum (n = 258, 49.6%). Participants who completed all assessments were Table 1.Participants’ sociodemographic characterization at baseline. Men Women Primiparous Multiparous Total n = 260% n= 260% n = 286% n = 234% n = 520% Age (years) ≤19 4.2 11.5 12.4 2.6 7.9 20–29 38.9 47.0 51.6 33.3 42.9 30–39 46.9 39.2 33.9 55.4 43.1 ≥40 10.0 2.3 2.1 8.7 6.1 Marital status Cohabiting 32.5 32.6 35.8 28.5 32.5 Married 55.7 55.8 49.7 63.2 55.8 Single 10.2 11.2 14.5 6.1 10.7 Divorced 1.6 .4 0 2.2 1.0 Socioeconomic level High 9.3 16.4 15.6 8.9 12.5 Medium– high 14.0 7.4 9.4 13.0 11.1 Medium 18.6 19.6 16.5 21.9 19.0 Medium–low 30.3 26.4 30.4 26.5 28.6 Low 27.8 30.2 28.1 27.7 28.8 Occupational status Employed 89.0 71.8 77.7 83.5 80.4 Unemployed 9.0 21.6 20.0 13.4 15.4 Household/student 2.0 6.6 5.3 3.1 4.2 Years of education <9 38.6 26.9 29.3 37.8 32.8 9–12 47.9 54.3 53.0 50.0 51.0 >12 13.5 18.8 17.7 12.2 16.2 Downloaded by [87.103.58.88] at 09:50 15 September 2017 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY 5 more likely to be older, χ2(3) = 33.05, p < .001, employed, χ2(6) = 16.32, p = .012, belong to medium or high socioeconomic levels, χ2(2) = 26.45, p < .001, and have more years of education, χ2(2) = 29.02, p < .001. Also, they reported fewer anxiety and depression symptoms at the first trimester, t(503) = 2.19, p = .03, t(503) = 4.05, p < .001, but not at 3 months postpartum. Most of the mothers delivered their babies after the 37th week of gestation (97%), began to breastfeed at childbirth (95.7%) and reported good health and developmental outcomes of their child at 30 months postpartum (95%). Measures Sociodemographic questionnaire Information about the participants (e.g. age, matrimonial status, socioeconomic level, occupational status and years of education) was collected using a sociodemographic questionnaire (Figueiredo, Teixeira, Conde, Pinto, & Sarmento, 2009). State–trait anxiety inventory The State–Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) is a self-report questionnaire that consists of two subscales, the state anxiety and the trait anxiety, each including 20 items (scored on a four-point Likert scale from 1 to 4). The state anxiety subscale (STAI-S), designed for measuring the temporary condition of anxiety (in a specific situation) was used in this study. Scores equal to or higher than 42 are considered to screen for anxiety states, focusing merely on the reported symptoms (Biaggio, Natalicio, & Spielberger, 1976) in women and men. A recent study with a Portuguese sample demonstrated reasonable validity of the STAI as a screening tool for anxiety in women over pregnancy and postpartum, pointing out an optimal cut-off value of 40 for pregnancy and of 34 for the postpartum period (Tendais, Costa, Conde, & Figueiredo, 2014). The STAI Portuguese version showed good internal consistency (α ranged from .87 to .93) (Biaggio et al., 1976). In the present sample, coefficient alphas ranged from .88 to .94 for men and women. Edinburgh Postnatal Depression Scale The Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky,1987) is a selfreport questionnaire composed of 10 items (scored on a four-point Likert scale from 0 to 3) to assess the existence and severity of depression symptoms. The scores range between 0 and 30. Scores equal or higher than 10 are considered to indicate depression (Cox et al., 1987). A recent study with a Portuguese sample demonstrated reasonable validity of the EPDS as a screening tool for depression in women over pregnancy and postpartum, pointing out an optimal cut-off value of 9 for pregnancy and of 7 for the postpartum period (Tendais et al., 2014). The EPDS Portuguese version showed good internal consistency (Cronbach’s alpha of .85) (Figueiredo, Pacheco, & Costa, 2007). The coefficient alphas in the present sample ranged from .78 to .88 for men and women. Procedure This research received previous approval from the institution Ethical Commission. Participants were recruited in an Obstetrics outpatients unit at their first pregnancy appointment. The exclusion criteria were not reading or writing Portuguese and multiple gestations. The aims Downloaded by [87.103.58.88] at 09:50 15 September 2017 6 C. CANÁRIO AND B. FIGUEIREDO and the procedures of the study were explained. After signing an informed consent, the sociodemographic questionnaire, STAI and EPDS were separately administered to the pregnant woman and partner (between weeks 8 and 14, M = 13.90, SD = 1.38). The STAI and the EPDS were then sent by letter or email, using an electronic form, during the second (between weeks 20 and 24, M = 21.21, SD = 1.14) and third pregnancy trimester (between weeks 30 and 34, M = 31.14, SD = 1.65), as well as at childbirth (between days 1 and 3, M = 2.30, SD = 0.51), at 3 (between weeks 10 and 14, M = 13.60, SD = 0.80) and 30 months (between weeks 24 and 36, M = 30.20, SD = 5.51) postpartum. Data structure and analytic model Statistical analysis was performed with IBM SPSS Statistics for Windows, v.19.0. Descriptive statistics were performed for each outcome variable at each assessment wave (Table 2). Bivariate Pearson correlations were performed to assess correlations between men and women at each assessment wave, within-men correlations and within-women correlations (Table 3). Paired-sample t-tests were performed to compare the outcome variables between the first and last assessment waves. Dyadic growth curve models were tested using multilevel modelling (MLM; Kenny et al., 2006) to estimate women’s and men’s trajectories of change for anxiety and depression symptoms over time, and symptoms’ within-dyad interdependence. Two-level models 1 were estimated for anxiety and depression symptoms (outcome variables), in which level 1 referred to the participants’ score at each time point and level 2 to the dyad. Individual differences for men and women were modelled at the dyad level (Kenny et al., 2006). In each model, time 0 was defined as the date of the first assessment at the first trimester (baseline) and the time variable was scored in months since the baseline until the child’s age of 30 months. Piecewise linear growth curve models (Duncan, Duncan, & Strycker, 2006) were performed to assess the changes on the outcome variables at baseline, from baseline Table 2.Means for anxiety and depressive symptoms for men and women, primiparous and multiparous. Symptoms Men Women Primiparous Multiparous MSDMSDMSDMSD Anxiety 1st trimester 33.10 8.83 36.04 8.88 33.91 8.92 35.39 8.87 2nd trimester 31.17 8.07 34.68 9.37 31.51 7.90 34.76 9.79 3rd trimester 32.61 7.95 36.24 9.03 32.90 7.98 36.46 9.17 Childbirth 32.72 9.13 35.76 10.25 33.99 10.61 34.62 8.77 3 months postpartum 29.37 7.99 30.84 8.36 28.99 7.80 31.51 8.49 30 months postpartum 33.77 9.43 34.45 9.48 32.31 8.28 36.79 10.41 Depressive 1st trimester 5.24 3.96 6.42 4.19 5.42 4.08 6.34 4.07 2nd trimester 4.18 3.31 6.00 4.32 4.74 3.86 5.59 4.07 3rd trimester 4.08 3.26 5.49 4.25 4.30 3.75 5.45 3.92 Childbirth 4.06 3.73 5.87 4.67 4.72 4.39 5.30 4.23 3 months postpartum 3.51 3.46 4.72 4.21 3.62 3.73 4.75 4.03 30 months postpartum 4.80 4.21 6.11 4.36 4.82 3.84 6.47 4.82 Downloaded by [87.103.58.88] at 09:50 15 September 2017 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY 7 to 3 months postpartum, and from 3 to 30 months postpartum. Two different multilevel models were performed to predict anxiety and depression symptoms. Each model included time from the first trimester to 3 months postpartum, time from 3 to 30 months postpartum, gender and parity, and all possible interactions, as predictors of the outcome variables (Table 4, Figures 1 and 2). The fixed and random effects are presented in Table 4. The deviance difference tests revealed that the models provided good fits to the data. Results were reported at a p < .05 significance level. Results Preliminary analyses Descriptive statistics (mean and standard deviation) for men’s and women’s, primiparous and multiparous parents’ anxiety and depression symptoms at each assessment wave are presented in Table 2. Correlations among partners’ symptoms for all assessment waves were statistically significant, ps < .001 (Table 3). Men’s and women’s scores for the outcome variable at each assessment wave were positively correlated. Regarding anxiety and depression symptoms, between partner’s correlations at each time point were medium to high size (rrange = .31–.55), except for the correlation between women’s and men’s anxiety symptoms at the first trimester, which was small (r = .16). Additionally, within-men and within-women correlations of the outcome variables show that men’s and women’s anxiety and depression symptoms are related over time. Within-women and within-men correlations of anxiety symptoms ranged from small (rwomen = .28; rmen = .25) to high size (rwomen = .60; rmen = .65). Within-women and within-men correlations of depression symptoms ranged from medium (rwomen = .45; rmen = .37) to high size (rwomen = .70; rmen = .69). Table 3.Correlations among anxiety and depressive symptoms for men and women. Note: Values on the diagonal (in bold) represent correlations between men and women, values above the diagonal represent within-men correlations, and values below the diagonal represent within-women correlations. All correlations were significant at a p<.001 level. 1st trimester 2nd trimester 3rd trimester Childbirth 3 months postpartum 30 months postpartum Anxiety symptoms 1st trimester .16 .54 .57 .51 .43 .34 2nd trimester .60 .31 .65 .44 .54 .34 3rd trimester .54 .59 .41 .59 .55 .39 Childbirth .36 .36 .52 .52 .56 .25 3 months postpartum .41 .39 .51 .49 .31 .38 30 months postpartum .36 .31 .47 .28 .40 .49 Depressive symptoms 1st trimester .31 .69 .67 .60 .51 .37 2nd trimester .62 .32 .69 .60 .54 .37 3rd trimester .49 .70 .37 .68 .54 .50 Childbirth .49 .59 .65 .55 .60 .50 3 months postpartum .46 .62 .63 .69 .44 .46 30 months postpartum .45 .51 .56 .53 .51 .42 Downloaded by [87.103.58.88] at 09:50 15 September 2017 8 C. CANÁRIO AND B. FIGUEIREDO Table 4.Anxiety and depressive symptoms from early pregnancy to 30 months postpartum: gender and parity differences and effects. Note: Gender: –1 female, 1 male; Parity: –1 first-time parents, 1 second-time parents. *p<.05; **p<.01; ***p<.001. Symptoms Anxiety Depressive Fixed effects b SE 95% CI b SE 95% CI Intercept 34.74 0.42 [33.920, 35.56]*** 5.36 0.19 [4.99,5.74]*** Time from first trimester to 3 months postpartum −0.32 0.05 [–0.41, −0.23]*** −0.12 0.02 [–0.17, −0.07]*** Time from 3 to 30 months postpartum 0.11 0.02 [0.07, 0.15]*** 0.05 0.01 [0.03, 0.07]*** Gender −1.72 0.32 [–2.35, −1.09]*** −1.05 0.18 [–1.42, −0.69]*** Parity 0.83 0.39 [0.05, 1.62]* 0.40 0.19 [0.03, 0.78]* Gender × Parity 0.01 0.32 [–0.63, 0.65] −0.24 0.18 [–0.60, 0.13] Gender × Time from first trimester to 3 months postpartum 0.09 0.04 [–0.01, 0.17] 0.04 0.02 [–0.004, 0.08] Gender × Time from 3 to 30 months postpartum 0.02 0.02 [–0.02, 0.06] 0.003 0.01 [–0.01, 0.02] Parity × Time from first trimester to 3 months postpartum −0.01 0.04 [–0.09, 0.08] 0.01 0.02 [–0.04, 0.05] Parity × Time from 3 to 30 months postpartum 0.03 0.02 [–0.0, 0.07] 0.01 0.01 [–0.01, 0.03] Gender × Parity× Time from first trimester to 3 months postpartum 0.06 0.04 [–0.03, 0.14] 0.05 0.02 [–0.01, 0.09]* Gender × Parity × Time from 3 to 30 months postpartum −0.06 0.02 [–0.09, −0.02]** −0.02 0.01 –0.03, −0.001]* Random effects Men Women Men Women Intercept 46.89*** 51.00*** 5.81*** 10.42*** Slope for time from first trimester to 3 months postpartum 0.22** 0.37** 0.04* 0.05* Slope for time from 3 to 30 months postpartum 0.06*** 0.03* 0.01*** 0.002 Residuals 24.36*** 30.18*** 3.60*** 6.56*** Downloaded by [87.103.58.88] at 09:50 15 September 2017 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY 9 Anxiety and depression symptoms from early pregnancy to 30 months postpartum Main effects of time were found in both anxiety and depression symptom models (Table 4). From the first trimester to 3 months postpartum, anxiety and depression symptoms decreased (the average person’s anxiety and depression symptoms decreased 0.32 units and 0.12 units per month, respectively). From 3 to 30 months postpartum, anxiety and depression symptoms increased (the average person’s anxiety and depression symptoms 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Depressive symptoms Assessment wave Multiparous women Multiparous men Primiparous women Primiparous men 1sttrimester 2nd trimester 3rd trimester Childbirth 3-months postpartum 30-months postpartum Figure 1.Depressive symptoms from early pregnancy to postpartum: gender and parity differences and effects. Significant differences are presented with a continuous line. 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 Anxiety symptoms Assessment waves Multiparous women Multiparous men Primiparous women Primiparous men 1sttrimester 2nd trimester 3rd trimester Childbirth 3-months postpartum 30-months postpartum Figure 2.Anxiety symptoms from early pregnancy to postpartum: gender and parity differences and effects. Significant differences are presented with a continuous line. Downloaded by [87.103.58.88] at 09:50 15 September 2017 16 C. CANÁRIO AND B. FIGUEIREDO Biaggio, A. M., Natalicio, L., & Spielberger, C. D. (1976). The development and validation of an experimental Portuguese form of the State-Trait Anxiety Inventory. In C. D. Spielberger, & R. DiasGuerrero (Eds.), Cross-cultural research on anxiety (pp. 29–40). Washington DC: Hemisphere/Wiley. Breitkopf, C. R., Primeau, L., Levine, R. E., Olson, G. L., Wu, Z. H., & Berenson, A. B. (2006). Anxiety symptoms during pregnancy and postpartum. Journal of Psychosomatic Obstetrics & Gynecology, 27, 157–162. doi:10.1080/01674820500523521 Buist, A., Gotman, N., & Yonkers, K. A. (2011). Generalized anxiety disorder: Course and risk factors in pregnancy. Journal of Affective Disorders, 131, 277–283. doi:10.1016/j.jad.2011.01.003 Canário, C., & Figueiredo, B. (2016). Partner relationship from early pregnancy to 30months postpartum: Gender and parity effects. Couple and Family Psychology: Research and Practice, 5, 226–239. doi:10.1037/cfp0000066 Chung, M. L., Moser, D. K., Lennie, T. A., & Rayens, M. K. (2009). The effects of depressive symptoms and anxiety on quality of life in patients with heart failure and their spouses: Testing dyadic dynamics using Actor–Partner Interdependence Model. Journal of Psychosomatic Research, 67, 29–35. doi:10.1016/j.jpsychores.2009.01.009 Condon, J., & Esuvaranathan, V. (1990). The influence of parity on the experience of pregnancy: A comparison of firstand second-time expectant couples. The British Journal of Medical Psychology, 63, 369–377. doi:10.1111/j.2044-8341.1990.tb01632.x Cowan, P. A. (1991). Individual and family life transitions: A proposal for a new definition. In P.A. Cowan, & M. Hetherington (Eds.), Family transitions (pp. 3–30). Hillsdale, NJ: Lawrence Erlbaum Associates. Cowan, P. A., & Cowan, C. P. (2012). Normative family transitions, couple relationship quality, and healthy child development. In F. Walsh (Ed.), Normal family processes: Growing diversity and complexity (pp. 428–451). New York, NY: Guilford Press. Cowan, C. P., Cowan, P. A., Heming, G., & Miller, N. B. (1991). Becoming a family: Marriage, parenting and child development. In P. A. Cowan, & M. Hetherington (Eds.), Family transitions (pp. 79–110). Hillsdale, NJ: Lawrence Erlbaum Associates. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10item Edinburgh postnatal depression scale. British Journal of Psychiatry, 150, 782–786. doi:10.1192/ jpb.150.6.782 Dekel, R., Vilchinsky, N., Liberman, G., Leibowitz, M., Khaskia, A., & Mosseri, M. (2014). Marital satisfaction and depression among couples following men’s acute coronary syndrome: Testing dyadic dynamics in a longitudinal design. British Journal of Health Psychology, 19, 347–362. doi:10.1111/bjhp.12042 Di Florio, A., Jones, L., Forty, L., Gordon-Smith, K., Robertson Blackmore, E., Heron, J., & Craddock, I. (2014). Mood disorders and parity: A clue to the aetiology of the postpartum trigger. Journal of Affective Disorders, 152-154, 334–339. doi:10.1016/j.jad.2013.09.034 Dipietro, J., Costigan, K., & Sipsma, H. (2008). Continuity in self-report measures of maternal anxiety, stress, and depressive symptoms from pregnancy through two years postpartum. Journal of Psychosomatic Obstetrics & Gynecology, 29, 115–124. doi:10.1080/01674820701701546 Direção-Geral da Saúde. (2013). Registo do aleitamento materno: Relatório janeiro a dezembro de 2011. Stable url. Retrieved from. https://www.dgs.pt/?cr=24421 Don, B. P., & Mickelson, K. D. (2012). Paternal postpartum depression: The role of maternal postpartum depression, spousal support, and relationship satisfaction. Couple and Family Psychology: Research and Practice, 1, 323–334. doi:10.1037/a0029148 Don, B. P., Chong, A., Biehle, S. N., & Mickelson, K. D. (2014). Anxiety across the transition to parenthood : Change trajectories among low-risk parents. Anxiety, Stress, & Coping: An International Journal, 27, 37–41. doi:10.1080/10615806.2014.903473 Dubber, S., Reck, C., Müller, M., & Gawlik, S. (2015). Postpartum bonding: The role of perinatal depression, anxiety and maternal-fetal bonding during pregnancy. Archives of Women’s Mental Health, 18, 187– 195. doi:10.1007/s00737-014-0445-4 Dudley, M., Roy, K., Kelk, N., & Bernard, D. (2001). Psychological correlates of depression in fathers and mothers in the first postnatal year. Journal of Reproductive and Infant Psychology, 19, 187–202. doi:10.1080/02646830120073206 Duncan, T., Duncan, S., & Strycker, L. (2006). An introduction to latent growth curve modeling: Concepts, issues and applications (2nd ed.). New Jersey: Lawrence Erlbaum Associates. Escriba-Aguir, V., & Artazcoz, L. (2011). Gender differences in postpartum depression: A longitudinal cohort study. Journal of Epidemiology & Community Health, 65, 320–326. doi:10.1136/jech.2008.085894 Downloaded by [87.103.58.88] at 09:50 15 September 2017 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY 17 Escribe-Aguir, V., Gonzalez-Galarzo, M., Barona-Vilar, C., & Artazcoz, L. (2008). Factors related to depression during pregnancy: Are there gender differences? Journal of Epidemiology & Community Health, 62, 410–414. doi:10.1136/jech.2007.063016 Farr, S. L., Dietz, P. M., O’Hara, M. W., Burley, K., & Ko, J. Y. (2014). Postpartum anxiety and comorbid depression in a population-based sample of women. Journal of Women’s Health, 2, 120–128. doi:10.1089/jwh.2013.4438 Figueiredo, B., Pacheco, A., & Costa, R. (2007). Depression during pregnancy and the postpartum period in adolescent and adult Portuguese mothers. Archives of Women’s Mental Health, 10, 103–109. doi:10.1007/s00737-007-0178-8 Figueiredo, B., Teixeira, C., Conde, A., Pinto, A. R., & Sarmento, P. (2009). Socio-demographic, medical and psychological characterization of the Júlio Dinis Maternity Hospital Outpatient Unit users. Revista Portuguesa de Psicologia, 41, 45–64. Figueiredo, B., Canário, C., & Field, T. (2014). Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychological Medicine, 44, 927–936. doi:10.1017/ S0033291713001530 Garfield, C. F., Duncan, G., Rutsohn, J., McDade, T. W., Adam, E. K., Coley, R. L., & Chase-Lansdale, P. L. (2014). A longitudinal study of paternal mental health during transition to fatherhood as young adults. Pediatrics, 133, 836–843. doi:10.1542/peds.2013-3262 Giallo, R., Woolhouse, H., Gartland, D., Hiscock, H., & Brown, S. (2015). The emotional-behavioural functioning of children exposed to maternal depressive symptoms across pregnancy and early childhood: A prospective Australian pregnancy cohort study. European Child & Adolescent Psychiatry, 24, 1233–1244. doi:10.1007/s00787-014-0672-2 Giardinelli, L., Innocenti, A., Benni, L., Stefanini, M., Lino, G., Lunardi, C., … Faravelli, C. (2012). Depression and anxiety in perinatal period: Prevalence and risk factors in an Italian sample. Archives of Women’s Mental Health, 15, 21–30. doi:10.1007/s00737-011-0249-8 Hakulinen, T., Laippala, P., & Paunonen, M. (1998). Relationships between infant temperament, demographic variables, and family dynamics of childrearing families. Journal of Advanced Nursing, 27, 458–465. doi:10.1046/j.1365-2648.1998.00558.x Henderson, J., & Redshaw, M. (2016). Worries about labor and birth: A population-based study of outcomes for young primiparous women. Birth, 43, 151–158. doi:10.1111/birt.12219 Heron, J., O’Connor, T., Evans, J., Golding, J., & Glover, V. (2004). The course of anxiety and depression through pregnancy and the postpartum in a community sample. Journal of Affective Disorders, 80, 65–73. doi:10.1016/j.jad.2003.08.004 Huizink, A. C., Mulder, E. H., Robles de Medina, P. G., Visser, G. A., & Buitelaar, J. K. (2004). Is pregnancy anxiety a distinctive syndrome? Early Human Development, 79, 81–91. Keeton, C. P., Perry-Jenkins, M., & Sayer, A. G. (2008). Sense of control predicts depressive and anxious symptoms across the transition to parenthood. Journal of Family Psychology, 22, 212–221. doi:10.1037/0893-3200.22.2.212 Kenny, D. A., Kashy, D. A., & Cook, W. L. (2006). Dyadic data analysis. New York, NY: The Guilford Press. Kerstis, B., Engström, G., Edlund, B., & Aarts, C. (2013). Association between mothers’ and fathers’ depressive symptoms, sense of coherence and perception of their child’s temperament in early parenthood in Sweden. Scandinavian Journal of Public Health, 41, 233–239. doi:10.1177/1403494812472006 Kessler, R. C., Keller, M. B., & Wittchen, H. (2001). The epidemiology of generalized anxiety disorder. Psychiatric Clinics of North America, 24, 19–39. doi:10.1016/S0193-953X(05)70204-5 Kishi, R., McElmurry, B., Vonderheid, S., Altfeld, S., McFarlin, B., & Tashiro, J. (2011). Japanese women’s experiences from pregnancy through early postpartum period. Health Care for Women International, 32, 57–71. doi:10.1080/07399331003728634 Kjærgaard, H., Wijma, K., Dykes, A., & Alehagen, S. (2008). Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark. Journal of Reproductive & Infant Psychology, 26, 340–350. Lee, A. M., Lam, C. S. Y., Sze Mun Lau, H. W., Chong, S. K., & Chui, D. Y. T. (2007). Prevalence, course, and risk factors for antenatal anxiety and depression. Obstetrics Gynecology, 110, 1102–1112. Matthey, S., & Ross-Hamid, C. (2012). Repeat testing on the Edinburgh Depression Scale and the HADS-A in pregnancy: Differentiating between transient and enduring distress. Journal of Affective Disorders, 141, 213–221. doi:10.1016/j.jad.2012.02.037 Matthey, S., Barnett, B., Ungerer, J., & Waters, B. (2000). Paternal and maternal depressed mood during the transition to parenthood. Journal of Affective Disorders, 60, 75–85. doi:10.1016/S01650327(99)00159-7 Downloaded by [87.103.58.88] at 09:50 15 September 2017 18 C. CANÁRIO AND B. FIGUEIREDO Matthey, S., Valenti, B., Souter, K., & Ross-Hamid, C. (2013). Comparison of four self-report measures and a generic mood question to screen for anxiety during pregnancy in English-speaking women. Journal of Affective Disorders, 148, 347–351. doi:10.1016/j.jad.2012.12.022 Melo, E. F., Cecatti, J. G., Pacagnella, R. C., Leite, D. F. B., Vulcani, D. E., & Makuch, M. Y. (2012). The prevalence of perinatal depression and its associated factors in two different settings in Brazil. Journal of Affective Disorders, 136, 1204–1208. doi:10.1016/j.jad.2011.11.023 deMontigny, F., Girard, M., Lacharité, C., Dubeau, D., & Devault, A. (2013). Psychosocial factors associated with paternal postnatal depression. Journal of Affective Disorders, 150, 44–49. doi:10.1016/j. jad.2013.01.048 Parfitt, Y., & Ayers, S. (2009). The effect of post-natal symptoms of post-traumatic stress and depression on the couple’s relationship and parent–baby bond. Journal of Reproductive and Infant Psychology, 27, 127–142. doi:10.1080/02646830802350831 Parfitt, Y., Pike, A., & Ayers, S. (2013). The impact of parents’ mental health on parent–baby interaction: A prospective study. Infant Behavior & Development, 36, 599–608. doi:10.1016/j.infbeh.2013.06.003 Parker, M. L., Johnson, N., & Ketring, S. A. (2012). Adult attachment and symptom distress : A dyadic analysis of couples in therapy. Journal of Family Therapy, 34, 321–344. doi:10.1111/j.14676427.2012.00598.x Paulson, J., & Bazemore, S. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: A meta-analysis. Journal of the American Medical Association, 303, 1961–1969. doi:10.1001/jama.2010.605 Perren, S., von Wyl, A., Bürgin, D., Simoni, H., & von Klitzing, K. (2005). Depressive symptoms and psychosocial stress across the transition to parenthood: Associations with parental psychopathology and child difficulties. Journal of Psychosomatic Obstetrics & Gynecology, 26, 173–183. doi:10.1080/01674820400028407 Pilkington, P. D., Whelan, T. A., & Milne, L. C. (2015). A review of partner-inclusive interventions for preventing postnatal depression and anxiety. Clinical Psychologist, 19, 63–75. doi:10.1111/cp.12054 Pinquart, M., & Teubert, D. (2010). A meta-analytic study of couple interventions during the transition to parenthood. Family Relations, 59, 221–231. doi:10.1111/j.1741-3729.2010.00597.x Rholes, W., Simpson, J., Kohn, J., Wilson, C., Martin, A., Tran, S., & Kashy, D. (2011). Attachment orientations and depression: A longitudinal study of new parents. Journal of Personality and Social Psychology, 100, 567–586. doi:10.1037/a0022802 Sekiyama, T., Nakatani, Y., Yu, X., Seki, Y., & Sato-Suzuki, I. (2013). Increased blood serotonin concentrations are correlated with reduced tension/anxiety in healthy postpartum lactating women. Psychiatry Research, 209, 560–565. doi:10.1016/j.psychres.2013.03.009 Singley, D. B., & Edwards, L. M. (2015). Men’s perinatal mental health in the transition to fatherhood. Professional Psychology: Research and Practice, 46, 309–316. doi:10.1037/pro0000032 Skouteris, H., Wertheim, E. H., Rallis, S., Milgrom, J., & Paxton, S. J. (2009). Depression and anxiety through pregnancy and the early postpartum: An examination of prospective relationships. Journal of Affective Disorders, 113, 303–308. doi:10.1016/j.jad.2008.06.002 Sockol, L. E., & Battle, C. L. (2015). Maternal attitudes, depression, and anxiety in pregnant and postpartum multiparous women. Archives of Women’s Mental Health, 18, 585–593. doi:10.1007/ s00737-015-0511-6 Spielberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. Stuebe, A. M., Grewen, K., & Meltzer-Brody, S. (2013). Association between maternal mood and oxytocin response to breastfeeding. Journal of Women’s Health, 22, 352–361. doi:10.1089/jwh.2012.3768 Sutter-Dallay, A., Cosnefroy, O., Glatigny-Dallay, E., Verdoux, H., & Rascle, N. (2012). Evolution of perinatal depressive symptoms from pregnancy to two years postpartum in a low-risk sample: The MATQUID cohort. Journal of Affective Disorders, 139, 23–29. doi:10.1016/j.jad.2011.08.018 Tendais, I., Costa, R., Conde, A., & Figueiredo, B. (2014). Screening for depression and anxiety disorders from pregnancy to postpartum with the EPDS and STAI. The Spanish Journal of Psychology, 17(e7), 1–9. doi:10.1017/sjp.2014.7 Downloaded by [87.103.58.88] at 09:50 15 September 2017 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY 19 van Bussel, J., Spitz, B., & Demyttenaere, K. (2009). Anxiety in pregnant and postpartum women: An exploratory study of the role of maternal orientations. Journal of Affective Disorders, 114, 232–242. doi:10.1016/j.jad.2008.07.018 Wenzel, A. (2011). Anxiety symptoms during pregnancy and the postpartum period. In A. Wenzel, & S. Stuart (Eds.), Anxiety in childbearing women: Diagnosis and treatment (pp. 21–35). Washington, DC: American Psychological Association. doi:10.1037/12302-001 Whisman, M. A., Davila, J., & Goodman, S. H. (2011). Relationship adjustment, depression, and anxiety during pregnancy and the postpartum period. Journal of Family Psychology, 25, 375–383. doi:10.1037/ a0023790 Wynter, K., Rowe, H., & Fisher, J. (2014). Interactions between perceptions of relationship quality and postnatal depressive symptoms in Australian, primiparous women and their partners. Australian Journal of Primary Health, 20, 174–181. doi:10.1071/PY12066 Zanardo, V., Gasparetto, S., Giustardi, A., & Suppiej, F. (2009). Impact of anxiety in the puerperium on breast-feeding outcomes: Role of parity. Journal of Pediatric Gastroenterology Nutrition, 49, 631–634. doi:10.1097/MPG.0b013e31819e6446 Downloaded by [87.103.58.88] at 09:50 15 September 2017