In the Boston area, the number of people hospitalized for COVID-19 is steadily decreasing.  This is obviously happy news and a long-awaited reason to celebrate; however, we continue to be concerned about the mental health of our patients, especially those who are pregnant.  Even in the best of times, women who are pregnant or have young families are acutely aware of the enormous responsibility they carry in caring for their families.  When the world presents new threats and challenges, normal worries can grow into fear and anxiety.   Two recent studies, one from China and the other from Quebec, have assessed the prevalence of psychiatric symptoms in pregnant women.   

Pregnant Women in Quebec, Canada

Berthelot and colleagues evaluated two cohorts of pregnant women.  One group was recruited before the COVID-19 pandemic (n = 496) through advertisements in prenatal clinics between April 2018 and March 2020, and the other (n = 1258) was recruited online during the pandemic between April 2nd and April 13th.  Prenatal distress and psychiatric symptomatology were measured using the Kessler Distress Scale (K10), Post-traumatic Checklist for DSM-5 (PCL-5), Dissociative Experiences Scale (DES-II), and Positive and Negative Affect Schedule (PANAS).

The 1754 pregnant women (mean age of 29.27, SD = 4.23) were between 4 and 41 gestational weeks (mean = 24.80 weeks, SD = 9.42), were generally educated (91.3% had post-high-school training), and financially well-resourced (85.3% were above the low-income cut-off). 

The researchers observed that 10.9% of the pregnant women in the COVID-19 cohort had clinically significant symptoms of anxiety and depression compared to only 6.0% of the pre?COVID?19 cohort (OR = 1.94).  Higher risk for depressive symptoms and anxiety were observed in women with a history of a psychiatric illness preceding the pandemic, younger age, lower household income, and lower education level.  

Pregnant Women in China

This study is a multi-center cross-sectional study that was initiated in early December 2019 before the COVID pandemic to identify psychiatric symptoms in pregnancy using the Edinburgh Postnatal Depression Scale (EPDS). This provided an opportunity to compare the mental status of pregnant women before and after the announcement of the COVID-19 epidemic. This cohort included a total of 4124 pregnant women during their third trimester from 25 hospitals in 10 provinces across China between January 1 to February 9, 2020; 1285 were assessed after January 20, 2020 when the coronavirus epidemic was publically announced, and 2839 were assessed before this time point. 

Pregnant women assessed after the declaration of the COVID-19 epidemic had higher rates of depressive symptoms (29.6% vs. 26.0%, P=0.02) than women assessed before the epidemic announcement. After the pandemic, women were also more likely to endorse thoughts of self-harm (adjusted risk ratio or aRR=2.85, 95% CI: 1.70, 8.85).

The prevalence of women with depressive symptoms rose as the daily number of new confirmed or suspected cases increased.  The number of women with elevated EPDS scores rose from 26.0% before the pandemic to 34.2% between February 5 to 9, 2020, the time during which the number confirmed and suspected cases was at its highest. 

Pregnant women who were underweight pre-pregnancy, primiparous, < 35 years old, employed full-time, and middle income were at increased risk for depression and anxiety symptoms during the outbreak.

While depression and anxiety were more common during the pandemic than before the pandemic, the magnitude of the increase was small (29.6% vs. 26.0%).  What was more striking is the high number of women who report symptoms of depression and anxiety even before the pandemic; one in 4 women reported depressive symptoms or anxiety, which is higher than observed in similar cross-sectional studies from other countries.  Also important to note is the 2.5-fold increase in thoughts of self-harm during the pandemic.  

Conclusion

Both studies demonstrate increases in depression and anxiety symptoms in pregnant women affected by the COVID-19 epidemic.  As both studies were cross-sectional, we do not know how long these symptoms persist.  Are the observed symptoms a transient response to a stressful event or do they trigger more persistent psychological symptoms?  We are just at the beginning, and it will take some time to fully understand the mental health consequences of the COVID-19 outbreak.

In the meantime, we must continue to screen women for depression and anxiety during pregnancy.  We have to keep in mind that some women may experience symptoms of anxiety or depression in this setting although these symptoms may not be severe or persistent enough to count as an episode of major depression or generalized anxiety disorder.  At the same time, we must make sure that we do not ignore or minimize the psychological distress women may report by simply viewing these symptoms as a “normal” response to a stressful situation.

Ruta Nonacs, MD PhD

Berthelot N, Lemieux R, Garon-Bissonnette J, Drouin-Maziade C, Martel É, Maziade M.  Uptrend in distress and psychiatric symptomatology in pregnant women during the COVID-19 pandemic.  Acta Obstet Gynecol Scand. 2020 May 25.

Wu Y, Zhang C, Liu H, et al. Perinatal depressive and anxiety symptoms of pregnant women along with COVID-19 outbreak in China.  Am J Obstet Gynecol. 2020 May 10. Free  Article