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Drug utilisation study, Psychotropic drugs, Antidepressant drugs, Pregnancy
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Perejón López D, Gascó Serna L, Serna Arnaiz MC et al. Prevalence and risk factors for depression in native and immigrant pregnant women in a Health Region- retrospective cohort study. [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1313 (https://doi.org/10.12688/f1000research.152015.1)
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Research Article
Prevalence and risk factors for depression in native and immigrant pregnant women in a Health Region- retrospective cohort study.
[version 1; peer review: awaiting peer review]
PUBLISHED 01 Nov 2024
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Abstract
Corresponding author:
Maria Catalina Serna Arnaiz
Competing interests:
No competing interests were disclosed.
Grant information:
PICARD grant, awarded by the Diptuació de Lleida. Picard I.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2024 Perejón López D et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Perejón López D, Gascó Serna L, Serna Arnaiz MC et al. Prevalence and risk factors for depression in native and immigrant pregnant women in a Health Region- retrospective cohort study. [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1313 (https://doi.org/10.12688/f1000research.152015.1)
First published: 01 Nov 2024, 13:1313 (https://doi.org/10.12688/f1000research.152015.1)
Latest published: 01 Nov 2024, 13:1313 (https://doi.org/10.12688/f1000research.152015.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Background
Perinatal mental disorders occur during pregnancy or 12 months after childbirth and are among the most common morbidities during pregnancy. Moreover, they are major contributors to maternal mortality and adverse neonatal, infant, and child outcomes.1 In particular, perinatal depression (PD) has a prevalence of 20% and 10-15% in developing and developed countries, respectively,1,2 and has been associated with an increased risk of preterm birth, miscarriage, foetal growth retardation, and low birth weight.3,4 Therefore, the fact that it is sometimes underdiagnosed and frequently untreated5 can have consequences for both the mother and the foetus or infant.
In Spain, the prevalence of depressive symptoms reported by Marcos-Najera et al. in 2021 is 10%.6 In another study carried out during the years 2014-2015 through screening with a questionnaire, The Patient Health Questionnaire (PHQ-9), they found a prevalence of moderate-high prenatal depression of 14.8%.7 In this study, those who did not complete the screening were more likely to be immigrants and were not able to read Spanish. In a further study in Spain during the years 2014-2017, they found that the native group presented a lower prevalence of depression (15.2%) than the immigrant group (25.8%).8 In agreement with this, ethnic minorities in Western countries are often exposed to stressors, such as problems arising from lack of social integration, language, and housing, and these factors can affect their mental health. Ethnicity and culture can also determine the inclination of these groups to request help from health services.9 Indeed, the prevalence of antidepressant use during pregnancy ranges between 1.8% and 8.0%, depending on the country and setting.9–11
Finally, although depression in pregnancy is recognized as a public health problem, there are few studies on pregnant women undergoing antidepressant treatment. In this context, we aimed to study the prevalence of depression under treatment both in the immigrant and native population in a Health Region of Spain.
Methods
Study design and data collection
We conducted a retrospective observational cohort study among pregnant women in the Health Region of Lleida between 2012 and 2018.
We included patients who gave birth at the Arnau de Vilanova Hospital between 1 January 2012 and 31 December 2018. This Hospital is the only reference hospital in the Health Region of Lleida. Data were obtained from the CMBD (“Conjunt Mínim de Base de Dades”), the E-CAP computerized clinical history database, and the Servei Català de Salut database. The latter collects the data of the prescriptions from the Servei Català de la Salut.
This study is part of a broader project, ILERPRENANT, which utilizes a shared database. The primary aim of the project was to analyze the population prevalence of various pathologies during pregnancy, as well as therapeutic prescription patterns and medication adherence.12
Participants
We included women who gave birth between January 1, 2012, and December 31, 2018. Pregnancy data were collected from the date of the last menstrual period until the date of delivery. Women who were not residents of the Health Region of Lleida were excluded from the study. To assess the representativeness of the sample, we calculated the percentage of pregnant women included in the study (those registered at Arnau de Vilanova University Hospital in Lleida) in comparison to the total number of pregnant women in the Health Region of Lleida, as recorded in the “Instituto de Estadística de Catalunya” (Idescat) database (Table 1).
Table 1. Number of births registered in the Health Region of Lleida and number of births in the sample studied with the percentage they represent by year.
| Year | Deliveries from Idescat | Deliveries from the sample | Idescat/sample |
|---|---|---|---|
| 2012 | 3788 | 3635 | 90% |
| 2013 | 3535 | 3370 | 89% |
| 2014 | 3592 | 3308 | 86% |
| 2015 | 3426 | 3162 | 86% |
| 2016 | 3283 | 3180 | 90% |
| 2017 | 3197 | 3034 | 88% |
| 2018 | 3029 | 3001 | 93% |
The primary outcome assessed was the presence or absence of depression. This was determined through diagnostic codes from the International Classification of Diseases, Ninth Revision (ICD-9), using codes 296.20 to 296.25, 296.30 to 296.35, 300.4, and 311, as obtained from outpatient physician claims, or the Tenth Revision (ICD-10), with codes F32.0 to F32.9, F33.0 to F33.3, F33.8, F33.9, F34.1, and F41.2 from the DAD and NACRS datasets. Additional recorded variables included age, body mass index (BMI), the presence of diabetes mellitus (ICD-10 code O24.9), arterial hypertension (ICD-10 codes I10-I16), and hypothyroidism (ICD-10 codes E03.9 and E02). Immigrant groups were classified by their region of origin, including Eastern Europe, the Maghreb, Sub-Saharan Africa, Latin America, and Others.13 Data on prescribed antidepressant medications were retrieved from the CIP, a comprehensive database that provides details on drug name, dosage, dispensation date, and quantity dispensed. Antidepressants were subsequently categorized into four groups according to the Anatomical Therapeutic Chemical (ATC) Classification System.
Data analysis
A descriptive analysis was carried out, where numerical variables were reported as mean with standard deviation, while categorical variables were expressed in terms of absolute and relative frequencies. Group comparisons were made using the Student’s t-test for numerical variables and the Chi-square test for categorical variables. The relationship between different variables and adherence was analyzed using a multivariate linear model, with adherence percentage serving as the outcome variable and other variables as predictors. Regression coefficients, Odds Ratios, and their corresponding 95% confidence intervals (CI) were estimated.
Results
Participants
We obtained a sample of 21375 pregnant women who had given birth at the Arnau de Vilanova Hospital in Lleida between 2012 and 2018 (both included). We excluded 1625 women who did not have a personal identification code (CIP), as well as 2573 women that lacked multiple clinical history data. As a consequence, the final sample was of 17177 patients (Figure 1). The average age was 30.5 years and 2.5% of the women (436) presented depression, with 0.1% of the cases20 being gestational.
Figure 1. Flowchart of pregnant women selection.
We observed no difference in the prevalence of depression by year of study. Pharmacological treatment had been prescribed for 24 % of patients diagnosed with depression (Table 2).
Table 2. Diagnosis of depression in pregnant women by year of study.
The patients with depression had an average age of 32 years (SD 5.56) compared to the rest of the women who had an average age of 30 (SD 5.85) years of age. Obesity was present in 17.7% of patients with depression compared to 14.3% in the rest.
According to geographical origin, women from Western Europe presented the highest prevalence of depression (2.9%), followed by women from Latin America (2.6%) and Eastern Europe (2.3%). Significantly lower prevalence was found among women from Africa (0.8%), and Asia and the Middle East (0.5%) (Table 3).
Table 3. Prevalence of depression and relationship with other parameters.
As for the pharmacological groups of drugs prescribed, 76.2% corresponded to the group “Selective serotonin reuptake inhibitors”, followed by “Selective serotonin-norepinephrine reuptake inhibitors” (12.4%), “Non-selective monoamines reuptake inhibitors” (5.7%), and “Atypical antidepressants” (3.8%) and tetracyclic antidepressant (1.9%). The most consumed drugs have been paroxetine, followed by sertraline, citalopram, and escitalopram (Table 4).
Table 4. Prescriptions during pregnancy according to the therapeutic group.
In the regression model, we show that the age that age and weight are related to depression. Also, we found the highest prevalence of depression among women from Western Europe, followed by women from Latin America and Eastern Europe. Finally, the prevalence of depression among women from Africa (0.8%), and Asia and the Middle East (0.4%), is significantly lower (Figure 2 and Table 5).
Figure 2. Multiple linear regression prevalence of depression in relation to different maternal variables.
Table 5. Multiple linear regression prevalence of depression in relation to different maternal variables.
Discussion
In our study, we analysed the prevalence of depression among pregnant women in the Health Region of Lleida between 2012 and 2018. We found a prevalence of 2.5%, and 24% of them received treatment. Similarly, Minguez et al. found a prevalence of use of antidepressant among pregnant women of 3.2%, and 2.7 in the first trimester and in the following ones, respectively.14 In our case, no variation in prevalence of depression under treatment was observed over the years. On the contrary, a study in Denmark showed that the rate increased from 0.2% in 1997 to 3.2% in 2010.15
We found that pregnant women with depression were older and had a higher BMI. In contrast to our study, Minguez et al. found no significant difference in the use of drugs according to age.14 Other studies identified as a risk factor being over 3016 or over 35.17 Finally, in some studies, depression has been even related to lower age.18,19 As for the BMI, the association of depression with obesity is complex because of the mutual influence between these two factors. On the one hand, there is evidence that women with depression have a higher risk of developing obesity20,21; on the other hand, it has also been shown that women with obesity are more likely to develop depressive symptoms during pregnancy and/or in the post-delivery period than women with a normal weight22–24
As for ethnic groups, Western European women showed the highest prevalence of depression (2.9%), followed by women from Latin America (2.6%) and Eastern Europe (2.3%). We observed a significantly lower prevalence among women from Africa (0.8%), and from Asia and the Middle East (0.4%). This lower prevalence that we observed in the immigrant population contrasts with another study carried out in Spain.8 Moreover, different results were obtained by a study in Oslo, in which the prevalence found were the following: 8.6% (95% CI: 5.4-11.7) for women from Eastern Europe; 19.5% (12.2-26.8) for women from the Middle East; 17.5% (12.0-22.9) for women from South Asia; and 11.3% (6.1-16.5) for other groups. When running logistic regression models, a significantly higher risk was found for women from the Middle East (OR=2.8, 95% CI 1.3-6.1) and South Asia (OR=2.7, 95% CI 1.3-5.5), in comparison to other minorities and women from Western Europe.25 Similarly, a study in the UK analysed 7824 women, of which 3514 were British and 4310 South Asian, showing that the South Asians were more predisposed to develop depression than the British (43.3% vs 36.1%, p<0.0001).26 In our study, the lower prevalence of depression in the immigrant population may be related to problems in accessibility to healthcare because of language and cultural barriers, as it has been referred to in other studies.27 Another key factor might be represented by the difference in the mean age of pregnant women in the native and immigrant populations. Other factors to consider are differences in the clinical presentation of the disease, with symptoms of somatization that make it difficult to suspect an affective problem.28 However, the low prevalence of depression in the immigrant population that we found in our study suggests a problem of lack of detection.
The overall estimated mean prevalence of depression is 12.0%,1 though some studies report rates as high as 20.0%.29 However, when focusing on the prevalence among patients receiving pharmacological treatment, the values are notably lower. For example, in a study across 15 countries,30 the prevalence of selective serotonin reuptake inhibitor (SSRI) use—the most commonly prescribed antidepressants—was found to be 3.0% (95% CI 2.3-3.7). Regionally, pooled prevalence estimates were 1.6% in Europe, 1.3% in Australasia, and 5.5% in North America. This meta-analysis highlights significant regional differences in antidepressant use during pregnancy, likely influenced by variations in prescribing practices, healthcare-seeking behaviours, and the structure of healthcare systems.
Among the prescribed pharmacological classes, 72.4% of the medications belonged to the “Selective serotonin reuptake inhibitors” group, followed by “Selective serotonin-norepinephrine reuptake inhibitors” (11.6%), “Non-selective monoamine reuptake inhibitors” (9.6%), and “Atypical antidepressants” (5.3%). In our study, paroxetine was the most commonly prescribed drug, followed by sertraline, citalopram, and escitalopram. This is noteworthy, given that paroxetine use has been linked to an increased risk of congenital cardiovascular malformations.31 In contrast, sertraline is recommended during pregnancy in several clinical guidelines due to its favorable lactation safety profile.32 Anderson et al. suggested that certain selective serotonin reuptake inhibitors, including venlafaxine and bupropion, may cause specific adverse effects in newborns, with venlafaxine showing the strongest impact, while escitalopram exhibited the least pronounce.31
The primary limitation of this study is the absence of socioeconomic data for the patients. Numerous studies have reported positive associations between low social support and the occurrence of antenatal depression, antenatal anxiety, and self-harm during pregnancy. Meta-analytic pooled estimates further highlight a significant positive association between low social support and antenatal depression (AOR: 1.2, 95% CI: 1.0, 1.4) as well as antenatal anxiety (AOR: 2.0, 95% CI: 1.3, 2.9).33 The main strength of this study lies in its analysis of clinical practice in a large population. Due to the universality of the Spanish healthcare system, all patients have access to healthcare and receive partial coverage for therapeutic prescriptions, ensuring that the data closely reflect real-world clinical information.
Conclusions
Finally, similar to other studies, we found prevalence of depression among pregnant women of 2.5%. Age and weight were the main factors associated with depression. Regarding ethnic groups, the highest prevalence was observed in women from Western Europe, followed by women from Latin America and Eastern Europe. The most prescribed drugs were Selective serotonin reuptake inhibitors, among which paroxetine was the most frequently used. In some ethnic groups, we observed a lower prevalence of pregnant women undergoing antidepressant treatment. This can be attributed to a possible under diagnosis of depression or variations in the therapeutic approach. In conclusion, pregnant women that are older or with higher BMI, or belong to some ethnic groups, may need additional outreach to facilitate assessment and treatment of depression. Further studies are needed to better define the prevalence of depression among pregnant women belonging to ethnic minorities and new public health policies must work in a context of multiculturalism.
Ethics approval and consent to participate
This study was approved by the ethics and clinical research committee “Institute for Primary Health Care Research Jordi Gol i Gurina (IDIAPJGol)” under the code 19/196-P, Approved on May 15, 2020. The study was conducted in accordance with the principles of the Declaration of Helsinki. We performed a pseudonymized retrospective descriptive cross-sectional study according to Additional Provision 17.2.d LOPD-GDD for research purposes, without the need to obtain the consent of the data holders. Thus, the consent was waived by the ethics committee. There was a technical and functional separation between the research team and the performer pseudonymization, and data are only accessible to the research team. Technical measures have been taken to prevent re-identification and access by third parties through the CMBD (“Conjunt Minim de Base de Dades”), the E-CAP computerized medical history database, and the Catalan Health Service database.
Authors’ contributions
DP and LG conceptualised the study, analysed the data, and wrote the first draft of the manuscript; MCS contributed to the design of the study, data management, and manuscript development and review; MO and JS contributed to the design of the study, creation of data bases, and data analysis; LG provided, validated, and helped to interpret pharmacological data; JP conceptualised the study and review of the manuscript draft. All authors read and approved the final manuscript.
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how to cite this article
Perejón López D, Gascó Serna L, Serna Arnaiz MC et al. Prevalence and risk factors for depression in native and immigrant pregnant women in a Health Region- retrospective cohort study. [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1313 (https://doi.org/10.12688/f1000research.152015.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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