Anxiety and depression symptoms in the same pregnant women before and during the COVID-19 pandemic

Study population

SARS-CoV-2 was first reported and confirmed officially by the Turkish Ministry of Health on March 11, 2020. Since June 1, 2018, we had already been conducting a prospective study evaluating the association between depression and anxiety scores and pregnancy-associated plasma protein-A levels measured at the time of first-trimester screening (11–14 weeks of gestation) in pregnant women at Istanbul Medeniyet University, Goztepe Training and Research Hospital. First-trimester ultrasound exams were consistently performed by the same sonographer (RA), and included the measurement of nuchal translucency (NT), the determination of fetal viability and the examination of certain anatomic structures (head, brain, stomach, abdomen, bladder, and extremities). All patients admitted to the outpatient clinic for first-trimester screening were also asked to complete the Inventory of Depression and Anxiety Symptoms II (IDAS II) and Beck Anxiety Inventory (BAI). These inventory scales were conducted prior to the outbreak of the SARS-COV-2 outbreak.

In their second or third trimester (during SARS-COV-2 pandemic), we retested those whose IDAS II and BAI scores were already available from the first-trimester testing, (before the SARS-COV-2 pandemic). The presence of SARS-CoV-2-related symptoms in the previous months (fever, cough, diarrhea, shortness of breath, sputum, myalgia) was investigated. Data were collected using the personal information form, the IDAS II and the BAI by the same researcher (RA) in face-to-face interviews. For each participant, detailed demographic data were recorded, including age, body mass index (BMI), gravida, parity, number of children, mode of previous delivery, elapsed time after the last delivery, education and income levels, employment, duration of marriage, partner’s education level, household size, comorbidities, migration status, the relationship with her husband, own family and husband’s family and her husband’s relationship with her family. History of mental health problems, obstetric history, pregnancy complications (threatened abortion, hyperemesis gravidarum, presence of diabetes mellitus, hypertension), intended or unintended pregnancy were evaluated. Only those who reside in Turkey, can speak and understand Turkish and have sufficient reading and writing skills to properly complete surveys were included in the study. We excluded those with a history of any psychiatric illness or those carrying an anomalous fetus from the study.

Clinical measures

The BAI questionnaire, which includes 21 items, screen for the presence of anxiety symptoms such as heart-pounding, nervousness, inability to relax, and dizziness, or light-headedness. The participant rated each question on a scale of 0–3. In this survey, overall total scores of 0–9 indicate normal or no anxiety, scores of 10–18 indicated mild to moderate anxiety, scores 19–29 shown moderate to severe anxiety, and scores 30–63 indicated severe anxiety. The Turkish version has previously been found to be reliable and valid [10].

In this study, the IDAS II was used to evaluate the depression and anxiety of the participants. The IDAS II, which includes 99 items, was developed by Watson to assess specific symptoms of major depression, anxiety disorders, and bipolar disorder. The Turkish validity and reliability studies were performed by Irak. The Turkish IDAS-II subscales revealed Cronbach’s alpha values ranged between 0.947 and 0.949 and the items have a relatively high internal consistency [11].

Ethical approval

Ethical approval was obtained from the Clinical Studies Ethics Committee of Istanbul Medeniyet University, Goztepe Training and Research Hospital, (2020/0400). Informed consent was taken from the participants in the study.

Power calculation and statistical analysis

All statistical analyses were performed using SPSS 18.0. A p-value of <0.05 was considered statistically significant. A power analysis was revealed that a sample of 54 patients was required to achieve a power of 0.95 in a test based on α=0.05. The power of the present study was calculated as 86.5%. The McNemar test was used to compare the results of BAI before and after the pandemic. A paired-samples t-test was used to compare the results of IDAS II before and after the SARS-COV-2 outbreak. Categorical variables were described through absolute frequencies and continuous variables through mean and standard deviation (SD). Multiple regressions were performed with the main characteristics of the participants as predictors and their factor score on each of the IDAS II and BAI.

Principal findings

To the best of our knowledge, this is the first study that compares the effect of SARS-CoV-2 pandemic condition on depression and anxiety symptoms in pregnant women both before and during the SARS-CoV-2 outbreak. This cross-sectional survey study revealed that coronavirus pandemic has a significant psychological impact on maternal physiological state, as confirmed by two different inventory scales including IDAS-II and BAI. To be able to assess depression and anxiety symptoms, using a single evaluation scale, instead of multiple scales, is preferred as it eliminates other factors related to common variances. Therefore, IDAS II was developed as a single comprehensive measure to assess diverse symptomatology while eliminating confounding methodological factors. Furthermore, the relationship with her husband and BMI were associated with a state of depression and anxiety during pregnancy regardless of pandemic conditions. This study indicates that pregnant women are vulnerable to mental state changes during the SARS-CoV-2 pandemic and deserve special care to cope with the high level of anxiety and depression generated by a period of uncertainty and stress.

Comparison with other studies

Pregnancy is a particularly vulnerable time and studies with measures of mental health reported that pregnant women experience higher levels of distress during an infectious disease outbreak [12]. In Turkey, the first case of SARS-CoV-2 was reported on 11 March 2020, after six days, the first death due to the SARS-CoV-2 occurred on 17 March. The Turkish government enacted strict rules, such as border closures, transportation restrictions, and quarantine to prevent the spread of infection and all these interventions were continued throughout the study period [13]. The prolongation of the pandemic will have inevitably devastating effects on individuals economically and financially, and as a consequence, undesirable effects on people’s mental health will also arise [14]. We conducted this study in a period when the SARS-CoV-2 spread was at its highest in our country and there was a lot of uncertainty about the course of the pandemic and the impact of SARS-CoV-2 infection on pregnancy.

Similar to our results, Wu et al. reported that the prevalence of depressive symptoms was positively associated with the number of newly confirmed cases of SARS-CoV-2, suspected infections, and deaths per day in China [15]. In Canada, 1987 pregnant women were evaluated and compared with previous community pregnancy cohorts in terms of anxiety, depression, and pregnancy-specific anxiety during the SARS-CoV-2 pandemic. They found that pregnant participants had higher level of depression, general anxiety, and pregnancy-specific anxiety symptoms than in previous community pregnancy cohorts with similar demographic profiles. However, unlike our study, in Lebel’s study, pregnant women across Canada were recruited via social media to complete an online survey [16]. Answering survey questions without the physical presence of the interviewer may have influenced the patients’ responses.

This cross-sectional study of an ongoing prospective cohort, compared depression and anxiety scores of the same women at different gestational ages before and following the SARS-CoV-2 pandemic by using IDAS II and BAI. Data on the specific effect of gestational age on anxiety and depression in pregnancy is still limited. Da Costa et al. evaluated the variations in stress levels over the course of pregnancy and they reported significantly higher pregnancy-specific stress in the first and third trimester of pregnancy [17]. In another study, the anxiety symptoms were determined by using the State-Trait Anxiety Inventory (STAI) and they found average STAI scores remained statistically stable over time throughout pregnancy [18].

On the contrary, the anxiety level of SARS-CoV-2 positive pregnant women was appeared low at the tail-end of the pandemic in the UK due to increased available clinical information and reassurance through social media, healthcare professionals, and primary care. However, the number of participants in that study was too few to reach a statistically valid result [19].

In our study, depression and anxiety scores were considerably higher during the pandemic than pre-pandemic scores in a cohort of pregnant women with similar demographic profiles. These results point out that SARS-CoV-2 may aggravate psychological challenges for pregnant women, with the potential for both short and long term impacts on the developing fetus. Mental health problems frequently go unnoticed and therefore untreated during pregnancy, but if discovered, treatment results in favorable outcomes.

Strengths and limitations

Some limitations and strengths should be taken into account when interpreting the results of our study. One limitation is the sample size but power analysis indicated that reduced the effect of this limitation. One of our strengths was while most other studies, administered questionnaires online, thus preventing a face-to-face evaluation of the participants, in our study, the same researcher contacted each patient face-to-face to complete the IDAS II and BAI interviews. The most striking strength of our study is the access to data on anxiety and depression in pregnancy we had fortuitously collected pre-pandemic, and our ability to compare these same data points to mid-pandemic surveys from the same group of women. Another important aspect of our study was the depth of detailed sociodemographic and clinical characteristics recorded for each participant. Because these sociodemographic parameters were mostly invariant during the study period, changes in test scores could more clearly be attributed to the onset of the pandemic and resultant psychological pressures.

Clinical and research implication

Pregnancy may increase the tendency towards anxiety and depression for some women. This change of mental health status is often associated with the offspring’s neurocognitive development, later psychopathologies, as well as maternal health and functioning. The SARS-CoV-2 pandemic may exacerbate pregnant women’s prenatal distress and psychiatric symptomatology. Critical new research is needed to evaluate the impact of maternal anxiety and depression due to the pandemic on the perinatal and postnatal outcomes, and long-term fetal neurobehavioral consequences. Intervention should be prioritized to ensure optimal perinatal and infant mental health. Obstetrician and mental health specialists can prevent adverse outcomes by identifying problems early and establishing comprehensive treatment plans for pregnant women in conditions such as extreme stress, emergencies and conflict situations, and natural disasters.