Prevalence of Serious Psychological Distress and Mental HealthTreatment in a National Sample of Pregnant and PostpartumWomen

Cristie Glasheen • Lisa Colpe • Valerie Hoffman •

Lauren Klein Warren

� Springer Science+Business Media New York (outside the USA) 2014

Abstract This study examines the prevalence and corre-

lates of past month serious psychological distress (SPD) and

past year mental health treatment (MHT) across pregnancy

and the postpartum. Data are from the 2008 to 2012 National

Surveys on Drug Use and Health. Prevalence estimates of

SPD as well as MHT among women with SPD were gener-

ated for each trimester and across the postpartum period.

Correlates of SPD and MHT were examined among pregnant

and postpartum women. The prevalence of past month SPD

was 6.4 % in first trimester women and 3.9 % in third tri-

mester women. In postpartum women, SPD prevalence

ranged from 4.6 % (0–2 months) to 6.9 % (3–5 months).

Correlates of SPD among pregnant and postpartum women

included being younger; non-Hispanic black; unmarried;

making under $20,000 annually; having past month cigarette

use; or having a past year alcohol or illicit drug use disorder.

Only 38.5 % of pregnant and 49.5 % of postpartum women

with past month SPD reported past year MHT. Those who

received MHT were more likely to be white; widowed,

divorced, or separated; have insurance; and have a history of

depression or anxiety than their counterparts with no MHT.

Pregnant women with SPD were less likely to report past

year MHT than postpartum women, even after adjusting for

potential confounders. Over half of pregnant and postpartum

women with past month SPD are not receiving MHT.

Increased contact with health care professionals during this

time may be an opportunity for screening, identification, and

referral to MHT.

Keywords Pregnancy � Postpartum � Psychological

distress � Mental health treatment � Mental health service

use

Introduction

Maternal distress during pregnancy and the postpartum

period may adversely affect fetal and early childhood

development [1–5] and have a negative impact on maternal

quality of life [6, 7]. Moreover, the severity of distress may

affect these outcomes [8, 9]. Despite this, few studies have

estimated the prevalence of serious psychological distress

(SPD) among pregnant or postpartum women from general

populations, and methodological issues with those studies

limit their generalizability [10, 11].

Previous studies have shown fluctuation in psychologi-

cal distress across pregnancy and the postpartum period.

Kearns et al. [11] examined patterns of psychological

distress from pregnancy into the postpartum period in a

small group of New Zealand women recruited from ante-

natal classes. Using the Edinburgh Postnatal Depression

Scale, the study found a decrease in psychological distress

from the third trimester through 10 weeks postpartum. In a

small study of women with low-risk pregnancies, DiPietro

et al. [10] followed women from the second half of preg-

nancy through 2 years postpartum and also found that

mean levels of psychological distress decreased from

C. Glasheen � V. Hoffman � L. K. Warren

RTI International, 3040 Cornwallis Rd., Research Triangle Park,

NC 27709, USA

e-mail: cglasheen@rti.org

V. Hoffman

e-mail: vhoffman@rti.org

L. K. Warren

e-mail: lklein@rti.org

L. Colpe (&)

National Institute of Mental Health, 6001 Executive Boulevard,

Bethesda, MD 20892-9663, USA

e-mail: Lisa.Colpe@nih.gov; lcolpe@mail.nih.gov

123

Matern Child Health J

DOI 10.1007/s10995-014-1511-2

pregnancy to 2 years postpartum but only among multip-

arous women. Psychological distress was lower and more

stable among primiparous women when compared with

distress levels of multiparous women. However, none of

these studies examined the prenatal and postpartum periods

with nationally representative samples.

Researchers have examined factors associated with

psychological distress during pregnancy and the post-

partum and found that pregnant and postpartum women are

at higher risk for distress if they are older [11, 12], are

single [13], have less education [12, 14–17], have low

social support [11, 14], are unemployed [12, 14, 18], or

have financial instability [12]. In addition, tobacco [19, 20],

alcohol use [20, 21], and prior psychological problems [16,

22] have been linked to distress among pregnant and

postpartum women.

One under researched area is mental health treatment

(MHT) among pregnant and postpartum women. Preg-

nancy and the postpartum are times of increased contact

with medical professionals and present opportunities for

women experiencing psychological distress to be identified

and advised of treatment options. One report using data

from a nationally representative study of US adults found

that pregnant women with psychiatric disorders were less

likely to seek MHT than nonpregnant women with psy-

chiatric disorders [23].

The current study uses US population-based data to

examine (a) the prevalence of SPD by pregnancy trimester

and postpartum period; (b) the demographic, health, and

behavioral correlates of SPD in pregnant and postpartum

women; and (c) the proportion and correlates of pregnant and

postpartum women with SPD who received MHT. Better

identification of the prevalence and correlates of SPD among

pregnant and postpartum women may help target screening

and treatment for women at high risk for SPD.

Methods

Sample

Data are from the 2008 to 2012 National Surveys on Drug

Use and Health (NSDUHs), a nationally representative

cross-sectional survey of the civilian, noninstitutionalized

US population aged 12 and older conducted by the Substance

Abuse and Mental Health Services Administration (SAM-

HSA). This stratified household-based survey covers resi-

dents of households, civilians living on military bases, and

persons in noninstitutional group quarters. Excluded from

the survey are persons with no fixed household address (e.g.,

homeless and/or transient persons not in shelters), active-

duty military personnel, and residents of institutional group

quarters, such as correctional facilities and mental

institutions. Data are collected in person using computer-

assisted interviewing (CAI) methods to provide a private and

confidential setting for the interview [24]. The primary

analytic sample consisted of women aged 18–44 who were

currently pregnant (n * 4,600), postpartum (n * 8,000),

and not pregnant or postpartum (n * 80,400). Women who

were missing trimester data (n \ 30) were excluded.

Measures

Pregnancy/Postpartum Status

Pregnancy status was self-reported. Postpartum status was

identified through questions asking respondents about the

age and number of biological children living in the

household. Women were classified as postpartum if they

had a biological child of 12 months or younger living in the

household. Women who were both pregnant and post-

partum were classified as pregnant.

Outcomes

There were two outcomes of interest: SPD and MHT. Past

month (30 days) psychological distress was measured using

the Kessler 6-item (K6) distress scale, a self-report screener

that evaluates nonspecific psychological distress and has

been clinically validated to maximize the scale’s discern-

ment of serious mental illness [25, 26]. A cut point of 13 or

higher is an indicator of SPD [27, 28]. Past year MHT was

defined as having received inpatient or outpatient treatment,

or prescription medication for ‘‘problems with emotions,

nerves, or mental health’’ in the 12 months before the survey,

not including treatment for alcohol or drug use.

Covariates

Covariates were drawn from the relevant literature and include

demographics, family environment, physical and mental health

status, and tobacco, alcohol, and drug use. Demographics

included age, race/ethnicity, marital status, education, employ-

ment, income, and poverty status [using the US Census Bureau’s

Federal Poverty Level calculation (FPL)]. Family environment-

related covariates included having had a rapid repeat birth

(defined in Healthy People 2010 as having two biological

children within 24 months of age of each other living in the

household [29]) and the number of biological children in the

household. Physical and mental health-related covariates

included health insurance status, overall health status, number of

significant health problems in the past year, and lifetime history

of depression or anxiety (respondent reported being diagnosed

with depression or anxiety by a doctor). Substance use included

past month cigarette use, past year alcohol use disorder, and past

year illicit drug use and illicit drug use disorder.

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Analyses

SPD Analyses

Prevalence estimates of SPD were generated for all preg-

nant women and for each trimester and for all postpartum

women and then grouped into four categories of post-

partum months (0–2, 3–5, 6–8, and 9–12 months post-

partum). Prevalence estimates were also estimated for

nonpregnant/nonpostpartum women. Differences in demo-

graphic characteristics between women with and without

SPD were evaluated among pregnant and postpartum

women. Statistical testing was conducted using Shah’s

Wald F tests (transformed from the standard Wald Chi

square) for overall significance to control for multiple

comparisons and t tests for post hoc comparisons of pro-

portions. T tests are used because the t-distribution more

accurately describes the test statistic under finite sample

sizes when the variances of the test statistic are estimated.

For more details, see the 2012 National Survey on Drug

Use and Health: Statistical Inference Report [30]. Multi-

variable logistic regression analyses were used to evaluate

the adjusted association of pregnancy status with SPD.

MHT Analyses

Prevalence estimates of MHT were generated for pregnant

and postpartum women with SPD, overall and by trimester/

postpartum category and among nonpregnant/non-

postpartum women. Differences in demographic character-

istics between women with SPD who did and did not receive

MHT were evaluated similar to the methods used for SPD.

For these analyses, pregnant and postpartum women with

SPD were combined to increase the sample size. Multivari-

able logistic regression analyses were used to evaluate the

adjusted association of pregnancy status with MHT.

All analyses were conducted using SUDAAN� [31] to

account for NSDUH’s complex survey design. All statistical

tests were two-tailed, with an alpha of 0.05; 95 % confidence

intervals (CIs) are also shown. The study was approved by

the RTI International Institutional Review Board.

Results

SPD

Prevalence of SPD

Past month SPD prevalence was similar in pregnant

(4.8 %) and postpartum women (5.4 %); these rates were

lower than the prevalence of SPD among nonpregnant/

nonpostpartum women (7.4 %; p \ 0.001 and p \ 0.001,

respectively; Fig. 1). Across trimesters, SPD prevalence

was 6.4 % in first trimester women, significantly higher

than the 4.3 % among second trimester women

(p = 0.036), and the 3.9 % among third trimester women

(p = 0.016). In postpartum women, SPD prevalence was

4.6 % at 0–2 months postpartum and then hovered between

5.1 % (9–12 months postpartum) and 6.9 % (3–5 months

postpartum). The prevalence of SPD in the first trimester

did not differ significantly from the prevalence in each of

the postpartum windows (p [ 0.05). Examining only

women who had been pregnant at least once, the preva-

lence of SPD increased linearly from 4.8 % among preg-

nant women to 5.4 % among postpartum women to 6.3 %

among women who had at least one biological child but

were not currently pregnant or postpartum (t test for linear

trend = 3.32, p \ 0.001).

The prevalence of SPD was significantly lower among

pregnant women aged 35–44 (0.8 %) than among post-

partum (3.2 %) and nonpregnant/nonpostpartum women

(5.9 %, Table 1). A similar pattern of differences (SPD

being lower among pregnant than among postpartum and

nonpregnant/nonpostpartum women) was seen among

married women, women with an annual income between

$50,000 and $74,999, women with a family income 200 %

or more above FPL, women who had had a prior rapid

repeat birth, and women with no serious health problems.

The prevalence of SPD across race/ethnicity, education,

employment, insurance status, health status, history of

depression or anxiety, past month cigarette use, and past

year alcohol or illicit drug use, did not differ by pregnancy

status.

Correlates of SPD Among Pregnant and Postpartum

Women

Correlates of past month SPD were largely similar among

pregnant and postpartum women (Table 2). SPD was

associated with being in the youngest age group (18–25),

being unmarried, having less education, being unemployed,

making \$20,000 annually, living below FPL, being in

good or fair/poor health, having a significant health prob-

lem, having a lifetime history of depression or anxiety,

smoking cigarettes in the past month, having an alcohol use

disorder in the past year, using illicit drugs in the past year

and having a past year illicit drug use disorder. Race/eth-

nicity was also associated with SPD. However, this asso-

ciation was not the same in pregnant and postpartum

women. An estimated 20.9 % of pregnant women with

SPD were black, compared with 13.1 % of pregnant

women without SPD. Among postpartum women, there

was no association between being black and having past

month SPD, but fewer postpartum women with SPD were

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123

Hispanic (14.5 %) than women without SPD (21.7 %).

Number of biological children in the household, and health

insurance status were not associated with SPD.

Adjusted Odds of SPD by Pregnancy Status

Evaluating the adjusted odds of past month SPD among

women aged 18–44 indicated that nonpregnant/non-

postpartum women had 50 % greater odds of SPD than

pregnant women [odds ratio (OR) 1.51, p \ 0.001; Table 3].

The odds of SPD was also higher among postpartum women

than pregnant women; however, this difference only

approached significance (OR 1.27, p = 0.051).

MHT

Prevalence and Pattern of MHT

Only 38.5 % of pregnant women, 49.5 % of postpartum

women, and 51.5 % of nonpostpartum/nonpregnant women

with past month SPD reported receiving MHT in the past

year (Fig. 2). The prevalence of MHT among pregnant

women ranged from 35.5 % among second trimester women

to 43.8 % among third trimester women. The prevalence of

MHT in the postpartum period ranged between 44.8 %

(3–5 months) to 53.6 % (9–12 months). The prevalence of

past year MHT was lower among pregnant women than

among postpartum women (p = 0.036) and nonpregnant/

nonpostpartum controls (p = 0.002).

The prevalence of MHT was lower among never married

pregnant or postpartum women (36.6 %; Table 1) than among

their nonpregnant/nonpostpartum counterparts (46.1 %).

Similarly, the prevalence of MHT was lower among pregnant

and postpartum women with an employment status of ‘‘other’’

(45.5 %) than among their nonpregnant/nonpostpartum

counterparts (60.7 %). A similar pattern of SPD prevalence

(lower in pregnant/postpartum women than their non-

pregnant/nonpostpartum counterparts) was seen among

women making \$20,000 annually, women with a family

income below the federal poverty threshold, women with one

or two biological children living in the household, women

with insurance, those with a health problem, and women who

did not smoke cigarettes in the past month. The prevalence of

MHT across pregnancy/postpartum status did not differ by

age, race/ethnicity, education, rapid repeat birth, health status,

and history of depression or anxiety.

Correlates of MHT Receipt Among Pregnant

and Postpartum Women

Pregnant and postpartum women with past month SPD who

received MHT in the past year were more likely to be

Fig. 1 Prevalence (and 95 % CI) of SPD among females aged 18–44 by pregnancy or postpartum status: annual averages, National Surveys on

Drug Use and Health, 2008–2012. Source 2008–2010 (revised 3/12) and 2011–2012 SAMHSA NSDUHs

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Table 1 Weighted prevalence of past month SPD and past year use of MHT by pregnancy/postpartum status and selected characteristics, among

women aged 18–44, percentage and standard error (SE)

Covariates SPD MHT among women with SPD

Nonpregnant and

nonpostpartum (*80,400)1Pregnant

(*4,600)

Postpartum

(*8,000)

Nonpregnant and

nonpostpartum (*6,700)1Pregnant or

postpartum (*900)

Age group

18–25 9.4 (0.18) 8.2 (0.63) 8.0 (0.49) 39.4 (0.94) 40.6 (2.51)

26–34 7.2 (0.28) 3.2 (0.63) 4.5 (0.62) 56.3 (1.99) 50.5 (5.65)

35–44 5.9a,b (0.25) 0.8b,c (0.48) 3.2a,c (0.87) 61.3 (2.10) * (*)

Race/ethnicity

White 7.8 (0.17) 4.6 (0.51) 5.9 (0.52) 60.9 (1.11) 55.4 (3.79)

Black 8.0 (0.38) 7.5 (1.37) 6.7 (0.90) 37.1 (2.77) 34.7 (5.59)

Other 5.6 (0.43) 2.9 (0.93) 4.7 (1.50) 33.2 (3.40) * (*)

Hispanic 6.1 (0.33) 4.5 (0.87) 3.7 (0.64) 33.1 (2.73) * (*)

Marital status

Married 4.9a,b (0.20) 2.4b,c (0.43) 3.6a,c (0.43) 55.6 (2.14) 52.3 (5.02)

Widowed, divorced, or

separated

10.3 (0.47) 9.9 (2.17) 15.0 (3.05) 61.6 (2.44) * (*)

Never married 9.0 (0.20) 8.4 (0.83) 7.0 (0.57) 46.1d (1.18) 36.6 (3.15)

Education

Less than high school 12.1 (0.52) 9.1 (1.31) 6.5 (0.79) 43.5 (2.32) 41.1 (4.49)

High school 9.3 (0.29) 7.0 (0.96) 8.4 (0.94) 47.9 (1.59) 41.9 (4.49)

Some college 7.5 (0.26) 4.4 (0.78) 5.3 (0.70) 55.6 (1.66) 49.1 (4.97)

College graduate 3.6 (0.19) 1.1 (0.34) 2.2 (0.52) 61.8 (2.61) * (*)

Employment status

Employed full time 5.2 (0.17) 3.4 (0.47) 4.7 (0.61) 50.5 (1.74) 46.6 (5.39)

Employed part time 7.1 (0.27) 3.7 (0.73) 4.2 (0.65) 44.6 (1.98) 39.7 (5.26)

Unemployed 13.0 (0.59) 10.6 (2.22) 11.2 (1.93) 42.9 (2.42) * (*)

Other (including not in labor

force)

10.8 (0.39) 5.8 (0.82) 5.8 (0.60) 60.7d (1.72) 45.5 (4.20)

Income

\$20,000 11.8 (0.36) 9.3 (1.07) 8.7 (0.89) 51.4d (1.53) 42.0 (3.87)

$20,000–$49,999 7.9 (0.25) 5.7 (0.78) 6.0 (0.66) 48.8 (1.63) 43.6 (4.34)

$50,000–$74,999 5.6a (0.32) 2.6b,c (0.68) 5.2a (1.07) 58.9 (2.81) * (*)

C$75,000 4.3 (0.21) 1.6 (0.55) 2.2 (0.48) 51.6 (2.48) * (*)

Federal poverty level (FPL)

Below FPL 12.0 (0.39) 9.2 (1.20) 8.5 (0.84) 49.2d (1.62) 39.0 (3.87)

100–199 % FPL 8.7 (0.31) 6.1 (0.92) 4.9 (0.59) 50.3 (1.88) 50.7 (4.80)

C200 % FPL 5.3a,b (0.16) 2.5b,c (0.39) 3.9a,c (0.55) 54.0 (1.56) 51.8 (5.69)

Rapid repeat birth

Current N/A 5.9 (1.13) 6.1 (0.80) N/A 44.4 (5.43)

Past 5.9a (0.34) 2.0b,c (0.71) 6.4a (1.34) 52.4 (2.90) * (*)

Neither 7.7 (0.16) 4.9 (0.47) 5.1 (0.44) 51.3 (1.04) 47.8 (3.50)

Number of biological children

in the household

0 8.6a (0.20) 5.1c (0.55) N/A 48.4 (1.19) N/A

1 7.2 (0.33) 4.5 (0.65) 6.0 (0.57) 56.4d (2.32) 45.9 (4.28)

2 5.4 (0.27) 4.5 (1.16) 4.9 (0.67) 55.9d (2.87) 42.7 (5.94)

C3 6.5 (0.43) 5.2 (1.81) 5.2 (0.74) 52.5 (3.46) * (*)

Health insurance

Has insurance 6.8 (0.16) 4.5 (0.40) 5.3 (0.42) 56.5d (1.15) 49.4 (3.11)

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white; have health insurance; have a history of depression

or anxiety; and have used cigarettes in the past month

(Table 2). Not receiving MHT was associated with being

black or of an ‘‘other’’ race/ethnicity, and having never

been married. Age, education, employment, income, pov-

erty, rapid repeat birth, the number of biological children in

the household, health status and significant health prob-

lems, past year illicit drug use, and past year alcohol or

illicit drug use disorder were not associated with past year

MHT among pregnant and postpartum women with SPD.

Adjusted Odds of MHT Receipt

Postpartum women with past month SPD had significantly

greater odds of having MHT in the past year than pregnant

women (OR 1.77, p = 0.045), after controlling for age,

race/ethnicity, marital status, education, employment sta-

tus, poverty status, history of rapid repeat birth, number of

biological children in the household, health insurance,

physical health status, number of physical health problems,

history of depression or anxiety, past month cigarette use,

Table 1 continued

Covariates SPD MHT among women with SPD

Nonpregnant and

nonpostpartum (*80,400)1Pregnant

(*4,600)

Postpartum

(*8,000)

Nonpregnant and

nonpostpartum (*6,700)1Pregnant or

postpartum (*900)

Does not have insurance 9.3 (0.33) 7.6 (1.88) 6.0 (0.89) 37.4 (1.70) * (*)

Health status

Excellent 3.1 (0.17) 1.8 (0.34) 2.4 (0.44) 38.9 (2.96) * (*)

Very good 5.6 (0.19) 3.5 (0.50) 4.5 (0.57) 48.1 (1.72) 50.7 (4.95)

Good 9.8 (0.31) 8.8 (1.17) 7.7 (0.90) 49.7 (1.68) 44.5 (4.60)

Fair/poor 22.1 (0.81) 19.9 (4.14) 19.6 (2.81) 63.6 (1.90) * (*)

Health problems

None 6.2a,b (0.16) 3.5b,c (0.38) 4.7a,c (0.40) 46.4 (1.29) 44.4 (3.65)

One 9.3 (0.35) 9.5 (1.35) 6.6 (0.82) 53.6d (1.88) 43.3 (4.83)

Two or more 16.3 (0.86) * (*) 17.5 (3.98) 73.8 (2.43) * (*)

History of depression

Yes 22.5 (0.55) 16.3 (1.84) 18.6 (1.77) 74.9 (1.15) 73.6 (3.57)

No 4.1 (0.12) 3.1 (0.36) 3.3 (0.31) 23.6 (1.22) 21.6 (3.32)

History of anxiety

Yes 22.9 (0.61) 15.8 (2.21) 17.7 (2.30) 79.2 (1.21) 77.7 (4.02)

No 5.0 (0.13) 3.7 (0.39) 4.2 (0.34) 32.8 (1.22) 32.6 (3.13)

Past month cigarette use

Yes 13.1 (0.36) 11.8 (1.45) 10.9 (1.04) 55.9 (1.36) 55.6 (4.04)

No 5.1 (0.14) 3.5 (0.39) 3.8 (0.37) 47.1d (1.42) 38.4 (3.69)

Past year alcohol use

disorder

Yes 18.1 (0.68) 19.3 (3.05) 25.4 (4.98) 53.1 (2.10) * (*)

No 6.4 (0.14) 4.0 (0.39) 5.0 (0.37) 51.1d (1.12) 44.0 (3.06)

Past year illicit drug use

No illicit drug use 5.5 (0.15) 3.4 (0.39) 4.4 (0.38) 50.1d (1.33) 42.8 (3.39)

Illicit drug use, no SUD 11.1 (0.38) 8.3 (1.34) 10.6 (1.65) 50.9 (1.84) * (*)

Illicit drug SUD 32.2 (1.28) 31.2 (4.65) 31.0 (4.61) 58.4 (2.30) * (*)

Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs)

N/A not applicable, SUD substance use disorder, * low precision, no estimate reported1 SAMHSA does not permit the reporting of exact sample sizes from the restricted data file to protect against the accidental identification of

respondents. Totals may not equal pregnant and postpartum women separately due to roundinga Difference between estimate and pregnant SPD estimate, p \ 0.05b Difference between estimate and postpartum SPD estimate, p \ 0.05c Difference between estimate and Nonpregnant and Nonpostpartum SPD estimate, p \ 0.05d Difference between estimate and pregnant/postpartum MHT/counseling estimate, p \ 0.05

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Table 2 Correlates of past month SPD and past year use of MHT among pregnant and postpartum women, aged 18–44, percentage and standard

error (SE)

Characteristic Pregnant women Postpartum women Pregnant or postpartum women

with SPD

SPD

% (SE)

No SPD

% (SE)

SPD

% (SE)

No SPD

% (SE)

MHT

% (SE)

No MHT

% (SE)

Age group

18–25 65.3 (4.71)** 36.9 (1.08) 48.4 (3.53)** 31.8 (0.71) 47.4 (4.04) 59.1 (4.00)

26–34 32.5 (4.74)** 49.6 (1.26) 41.2 (3.87)* 50.1 (0.94) 42.2 (4.58) 35.2 (3.82)

35–44 2.3 (1.29)** 13.6 (1.00) 10.4 (2.63)** 18.1 (0.91) 10.3 (3.34) 5.7 (1.95)

Race/ethnicity

White 56.7 (4.24) 59.8 (1.32) 61.4 (3.48) 56.4 (1.03) 72.2 (3.60)** 49.4 (3.87)

Black 20.9 (3.44)* 13.1 (0.75) 17.0 (2.21) 13.6 (0.63) 13.8 (2.68)* 22.1 (2.83)

Other 4.6 (1.45)* 7.9 (0.90) 7.2 (2.19) 8.3 (0.61) 2.6 (0.73)* 9.6 (2.76)

Hispanic 17.7 (3.14) 19.2 (1.05) 14.5 (2.31)** 21.7 (0.92) 11.5 (2.61) 19.0 (2.75)

Marital status

Married 30.3 (4.30)** 62.8 (1.19) 42.2 (3.57)** 63.9 (0.94) 43.8 (4.38) 33.9 (3.70)

Widowed, divorced, or separated 13.2 (2.72)* 6.1 (0.61) 17.8 (3.32)** 5.7 (0.53) 20.2 (4.14) 13.0 (2.71)

Never married 56.5 (4.21)** 31.1 (1.09) 40.1 (3.30)** 30.3 (0.88) 36.1 (3.81)** 53.0 (3.73)

Education

Less than high school 31.2 (3.83)** 15.7 (0.87) 20.0 (2.35) 16.4 (0.75) 21.1 (2.90) 25.7 (2.86)

High school 37.8 (4.14)** 25.2 (1.11) 42.5 (3.52)** 26.5 (0.77) 37.3 (4.20) 43.9 (3.35)

Some college 24.2 (3.67) 26.4 (1.12) 25.2 (2.97) 25.6 (0.85) 26.7 (3.39) 23.5 (2.91)

College graduate 6.9 (2.14)** 32.6 (1.29) 12.3 (2.65)** 31.5 (0.94) 15.0 (3.59) 6.9 (1.81)

Employment status

Employed full time 29.3 (3.61)** 42.0 (1.24) 32.5 (3.42) 37.9 (0.93) 31.9 (4.33) 31.1 (3.20)

Employed part time 13.3 (2.51) 17.4 (0.94) 13.7 (1.97)* 17.9 (0.70) 11.8 (2.10) 15.2 (2.16)

Unemployed 15.6 (3.13)** 6.7 (0.47) 12.0 (2.09)** 5.5 (0.36) 15.0 (3.17) 11.6 (1.72)

Other (including not in labor force) 41.8 (4.21) 34.0 (1.19) 41.8 (3.33) 38.8 (0.89) 41.4 (3.96) 42.1 (3.49)

Income

\$20,000 44.2 (4.10)** 21.8 (0.97) 37.5 (3.46)** 22.6 (0.76) 36.2 (4.08) 42.5 (3.38)

$20,000–$49,999 37.2 (4.13) 31.3 (1.15) 35.6 (3.20) 32.2 (0.89) 34.2 (3.73) 37.7 (3.31)

$50,000–$74,999 8.8 (2.24)** 16.6 (0.92) 15.9 (3.01) 16.7 (0.74) 18.0 (4.06) 9.9 (1.88)

C$75,000 9.7 (3.09)** 30.2 (1.30) 11.0 (2.27)** 28.6 (0.94) 11.5 (3.13) 9.9 (2.10)

Federal poverty level (FPL)

Below FPL 43.6 (4.18)** 21.8 (1.02) 43.7 (3.65)** 27.0 (0.86) 37.0 (4.15) 49.2 (3.59)

100–199 % FPL 27.3 (3.64) 21.2 (1.02) 21.6 (2.53) 23.8 (0.76) 25.9 (3.42) 21.4 (2.62)

C200 % FPL 29.0 (3.74)** 57.0 (1.28) 34.6 (3.64)** 49.2 (1.00) 37.1 (4.37) 29.3 (3.53)

Rapid repeat birth

Current 23.6 (3.98) 19.0 (0.98) 22.0 (2.68) 19.4 (0.76) 21.8 (3.15) 23.2 (3.11)

Past 3.9 (1.37)** 9.8 (0.80) 12.5 (2.42) 10.4 (0.64) 7.9 (2.17) 11.4 (2.62)

Neither 72.5 (4.05) 71.2 (1.15) 65.6 (3.17) 70.1 (0.91) 70.4 (3.61) 65.5 (3.49)

Number of biological children in the household

0 43.9 (4.03) 41.4 (1.19) N/A N/A 12.3 (2.23) 15.5 (2.06)

1 30.2 (3.70) 32.3 (1.18) 43.1 (3.40) 38.6 (0.95) 38.8 (4.04) 38.9 (3.40)

2 15.7 (3.64) 16.9 (0.94) 30.7 (3.38) 33.9 (0.92) 24.1 (3.79) 27.5 (3.56)

C3 10.3 (3.36) 9.5 (0.84) 26.2 (3.22) 27.5 (0.90) 24.7 (3.97) 18.1 (3.16)

Health insurance

Insured 86.2 (3.10) 91.6 (0.78) 80.2 (2.68) 82.3 (0.77) 88.3 (3.08) * 76.9 (3.05)

Uninsured 13.8 (3.10) 8.4 (0.78) 19.8 (2.68) 17.7 (0.77) 11.7 (3.08) 23.1 (3.05)

Health status

Matern Child Health J

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and past year alcohol and illicit drug use. The odds of past

year MHT was not significantly different among non-

pregnant/nonpostpartum women and pregnant women.

Discussion

In a nationally representative sample, the prevalence of

past month SPD was 4.8 % among pregnant women and

5.4 % among postpartum women. These prevalence esti-

mates appear lower than those reported by Ahluwalia,

Mack, and Mokdad (12.3 %) [20], Skari et al. [13] (9 %),

and Saurel-Cubizolles et al. [32] (8.7 %). However, there

are methodological differences that may account for dif-

ferences in prevalence and patterns over time. Our study

used the K6 instrument to detect SPD, whereas Skari et al.

[13] and Saurel-Cubizolles et al. [32] examined clinically

significant distress using the General Health Questionnaire,

and Ahluwalia et al. [20] used a measure of stress and

anxiety frequency from Health Related Quality of Life

indicators used in the Behavioral Risk Factor Surveillance

System. Thus, the prevalence estimates may reflect

differences in both instrumentation and the cut point for

distress. Furthermore, we report on the overall average

prevalence during the first year postpartum, whereas Skari

Table 2 continued

Characteristic Pregnant women Postpartum women Pregnant or postpartum women

with SPD

SPD

% (SE)

No SPD

% (SE)

SPD

% (SE)

No SPD

% (SE)

MHT

% (SE)

No MHT

% (SE)

Excellent 13.2 (2.35)** 35.8 (1.25) 13.9 (2.43)** 32.5 (0.92) 10.4 (2.11) 16.6 (2.76)

Very good 27.6 (3.41)** 38.6 (1.18) 33.5 (3.40)* 40.5 (0.91) 34.9 (4.29) 28.9 (2.83)

Good 42.1 (4.18)** 22.1 (0.95) 32.3 (3.25)** 22.2 (0.79) 34.2 (3.85) 36.3 (3.56)

Fair/poor 17.2 (3.44)** 3.5 (0.43) 20.3 (2.84)** 4.8 (0.42) 20.6 (3.42) 18.2 (2.89)

Health problems

0 56.8 (4.37)** 79.4 (0.96) 66.9 (3.08)** 78.7 (0.75) 61.5 (4.16) 65.7 (3.26)

1 36.6 (4.23)** 17.8 (0.91) 22.6 (2.60) 18.5 (0.73) 25.4 (3.56) 28.4 (3.06)

C2 6.6 (2.61) 2.8 (0.34) 10.4 (2.53)** 2.8 (0.28) 13.1 (3.38) 5.9 (1.91)

History of depression

Yes 44.3 (4.14)** 11.5 (0.75) 48.2 (3.39)** 12.2 (0.62) 75.1 (3.66)** 23.0 (2.96)

No 55.7 (4.14) 88.5 (0.75) 51.8 (3.39) 87.8 (0.62) 24.9 (3.66) 77.0 (2.96)

History of anxiety

Yes 29.3 (3.80)** 7.9 (0.62) 30.1 (3.42)** 8.0 (0.51) 50.4 (4.42)** 12.3 (2.12)

No 70.7 (3.80) 92.1 (0.62) 69.9 (3.42) 92.0 (0.51) 49.6 (4.42) 87.7 (2.12)

Past month cigarette use

Yes 39.4 (4.13)** 14.9 (0.82) 46.3 (3.51)** 21.7 (0.75) 53.3 (4.32)** 36.2 (3.29)

No 60.6 (4.13) 85.1 (0.82) 53.7 (3.51) 78.3 (0.75) 46.7 (4.32) 63.8 (3.29)

Past year alcohol use disorder

Yes 21.8 (3.32)** 4.6 (0.47) 10.3 (2.25)** 1.7 (0.21) 17.6 (3.42) 10.9 (1.87)

No 78.2 (3.32) 95.4 (0.47) 89.7 (2.25) 98.3 (0.21) 82.4 (3.42) 89.1 (1.87)

Past year illicit drug use

No illicit drug use 59.9 (4.08)** 86.6 (0.78) 72.2 (3.09)** 89.4 (0.55) 63.5 (4.08) 72.2 (2.87)

Illicit drug use, no SUD 19.8 (3.01)** 11.1 (0.73) 19.8 (2.90)** 9.6 (0.53) 21.2 (3.88) 18.7 (2.41)

Illicit drug SUD 20.3 (3.32)** 2.3 (0.27) 8.1 (1.39)** 1.0 (0.14) 15.3 (2.48) 9.1 (1.71)

Past year MHT

Yes 38.5 (4.04)** 10.4 (0.72) 49.5 (3.53)** 11.7 (0.60) 100 N/A

No 61.5 (4.04) 89.6 (0.72) 50.5 (3.53) 88.3 (0.60) N/A 100

Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs)

N/A not applicable, SUD substance use disorder, – low precision, no estimate reported

* Difference (t test of proportion) between SPD and no SPD or MHT and no MHT, p \ 0.05

** Difference (t test of proportion) between SPD and no SPD or MHT and no MHT, p \ 0.01

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Table 3 Adjusted odds of SPD among women aged 18–44 and adjusted odds of MHT among women aged 18–44 with SPD

Covariate Serious psychological distress Mental health treatment

B (SE) OR (95 % CI) p value B (SE) OR (95 % CI) p value

Pregnancy status

Pregnant Reference 1.00 – Reference 1.00 –

Postpartum 0.24 (0.12) 1.27 (1.00, 1.62) 0.051 0.57 (0.28) 1.77 (1.01, 3.09) 0.045

Not pregnant or postpartum 0.41 (0.10) 1.51 (1.24, 1.82) \0.001 0.32 (0.27) 1.38 (0.81, 2.33) 0.237

Age group

18–25 Reference 1.00 – Reference 1.00 –

26–34 -0.09 (0.06) 0.92 (0.82, 1.02) 0.116 0.33 (0.12) 1.40 (1.11, 1.76) 0.005

35–44 -0.28 (0.07) 0.76 (0.65, 0.88) \0.001 0.64 (0.15) 1.89 (1.42, 2.53) \0.001

Race/ethnicity

White Reference 1.00 – Reference 1.00 –

Black -0.16 (0.06) 0.85 (0.76, 0.95) 0.005 -0.40 (0.13) 0.67 (0.52, 0.88) 0.003

Other -0.18 (0.09) 0.83 (0.70, 0.99) 0.039 -0.94 (0.18) 0.39 (0.28, 0.55) \0.001

Hispanic -0.42 (0.07) 0.66 (0.58, 0.75) \0.001 -0.66 (0.16) 0.52 (0.38, 0.71) \0.001

Marital status

Married Reference 1.00 – Reference 1.00 –

Widowed/divorced/separated 0.34 (0.07) 1.41 (1.23, 1.61) \0.001 0.16 (0.16) 1.17 (0.86, 1.61) 0.316

Never married 0.09 (0.06) 1.09 (0.96, 1.23) 0.173 0.09 (0.13) 1.09 (0.84, 1.41) 0.499

Education

Less than high school -0.02 (0.06) 0.98 (0.87, 1.10) 0.718 -0.07 (0.14) 0.93 (0.71, 1.23) 0.625

High school Reference 1.00 – Reference 1.00 –

Some college -0.17 (0.05) 0.84 (0.76, 0.93) 0.001 0.21 (0.11) 1.24 (1.00, 1.53) 0.050

College graduate -0.53 (0.07) 0.59 (0.51, 0.68) \0.001 0.52 (0.15) 1.69 (1.27, 2.25) \0.001

Employment status

Employed full time Reference 1.00 – Reference 1.00 –

Employed part time 0.12 (0.06) 1.13 (1.01, 1.26) 0.026 -0.10 (0.12) 0.91 (0.71, 1.16) 0.437

Unemployed 0.48 (0.07) 1.61 (1.41, 1.84) \0.001 0.09 (0.14) 1.10 (0.83, 1.46) 0.511

Other (including not in the labor force) 0.42 (0.06) 1.52 (1.36, 1.70) \0.001 0.19 (0.12) 1.20 (0.95, 1.53) 0.125

Federal poverty level (FPL)

Below FPL 0.32 (0.05) 1.37 (1.23, 1.53) \0.001 0.14 (0.11) 1.15 (0.92, 1.44) 0.208

100–199 % FPL 0.17 (0.05) 1.19 (1.07, 1.32) 0.002 0.07 (0.11) 1.08 (0.86, 1.35) 0.529

C200 % FPL Reference 1.00 – Reference 1.00 –

Rapid repeat birth

Current 0.21 (0.14) 1.23 (0.93, 1.63) 0.152 0.04 (0.33) 1.05 (0.55, 1.99) 0.893

Past -0.06 (0.10) 0.94 (0.78, 1.14) 0.539 -0.14 (0.20) 0.87 (0.58, 1.30) 0.497

Neither Reference 1.00 – Reference 1.00 –

Number of biological children in the household

0 0.25 (0.08) 1.29 (1.11, 1.50) 0.001 0.02 (0.18) 1.02 (0.71, 1.46) 0.910

1 0.11 (0.08) 1.12 (0.97, 1.30) 0.134 0.12 (0.18) 1.13 (0.80, 1.59) 0.503

2 Reference 1.00 – Reference 1.00 –

C3 0.13 (0.09) 1.13 (0.95, 1.36) 0.171 0.01 (0.22) 1.01 (0.65, 1.57) 0.971

Health insurance

Insured Reference 1.00 – Reference 1.00 –

Uninsured -0.01 (0.05) 0.99 (0.90, 1.09) 0.774 -0.92 (0.10) 0.40 (0.33, 0.49) \0.001

Health status

Excellent Reference 1.00 – Reference 1.00 –

Very good 0.44 (0.07) 1.55 (1.36, 1.76) \0.001 -0.08 (0.15) 0.93 (0.70, 1.23) 0.604

Good 0.89 (0.07) 2.43 (2.13, 2.78) \0.001 -0.12 (0.15) 0.89 (0.66, 1.19) 0.440

Matern Child Health J

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et al. [13] report prevalence estimates a few days after

birth. Additionally, the study by Saurel-Cubizolles and

et al. [32] was conducted in France; cultural variation

potentially could affect the comparability of results.

Our finding that the prevalence of past month distress

was lower among pregnant and postpartum women than

among nonpregnant/nonpostpartum women was consistent

with other studies that have compared prevalence estimates

in these groups. Ahluwalia et al. [20] found that frequent

mental distress was more common among nonpregnant

women than among pregnant women. Similarly, Wallace

et al. [33] and Saurel-Cubizolles et al. [32] found that the

lowest prevalence of psychological distress was among

pregnant women, compared with postpartum and non-

pregnant/nonpostpartum women.

This study demonstrates a linear increase in past month

SPD prevalence in pregnant, postpartum, and nonpregnant/

nonpostpartum women who had at least one biological

child in the household. Previous within-person studies

generally have found women to have stable or decreasing

levels of psychological distress from pregnancy through

postpartum [10, 11, 13, 14, 34]. However, comparisons

must be made with caution because studies examining

symptom course in individuals often examine changes in

overall mean levels of psychological distress [10, 11, 14]

and not among individuals meeting a clinical cut point for

SPD. It may be that the patterns are different for women

reaching clinical thresholds than for women with lower

distress scores. Both of these possibilities present an

opportunity for future research.

Correlates of past month SPD were similar in pregnant

and postpartum women. Notably, more than 4 times as

many pregnant and postpartum women with SPD reported

past year alcohol or illicit drug use disorders than pregnant

and postpartum women without SPD; more than twice as

many women with SPD reported past month cigarette use

than women without SPD. This suggests that physicians

who identify pregnant or postpartum women with SPD may

need to pay particular attention to smoking, alcohol, and

drug use behaviors. Physicians identifying these behaviors

in pregnant and postpartum women should also be aware of

the increased odds of SPD in these women. Other corre-

lates indicated that younger women, unmarried women,

and women of lower socioeconomic status (less education,

Table 3 continued

Covariate Serious psychological distress Mental health treatment

B (SE) OR (95 % CI) p value B (SE) OR (95 % CI) p value

Fair/poor 1.66 (0.08) 5.24 (4.51, 6.08) \0.001 0.18 (0.16) 1.20 (0.87, 1.65) 0.277

Health problems

0 Reference 1.00 – Reference 1.00 –

1 0.24 (0.05) 1.27 (1.15, 1.41) \0.001 0.18 (0.10) 1.20 (0.98, 1.47) 0.080

C2 0.60 (0.08) 1.82 (1.57, 2.11) \0.001 0.43 (0.16) 1.54 (1.12, 2.11) 0.008

Past month cigarette use

Yes 0.33 (0.05) 1.39 (1.26, 1.53) \0.001 0.11 (0.10) 1.11 (0.91, 1.36) 0.306

No Reference 1.00 – Reference 1.00 –

Past year alcohol use disorder

Yes 0.71 (0.06) 2.04 (1.81, 2.30) \0.001 0.11 (0.12) 1.11 (0.88, 1.41) 0.373

No Reference 1.00 – Reference 1.00 –

Past year illicit drug use

No illicit drug use Reference 1.00 – Reference 1.00 –

Illicit drug use, no SUD 0.37 (0.05) 1.44 (1.30, 1.61) \0.001 -0.12 (0.11) 0.89 (0.71, 1.10) 0.273

Illicit drug SUD 1.28 (0.07) 3.58 (3.11, 4.13) \0.001 0.25 (0.14) 1.28 (0.98, 1.67) 0.069

History of depression

Yes N/A N/A N/A 1.70 (0.09) 5.50 (4.58, 6.60) \0.001

No N/A N/A N/A Reference 1.00 –

History of anxiety

Yes N/A N/A N/A 1.30 (0.10) 3.66 (2.98, 4.49) \0.001

No N/A N/A N/A Reference 1.00 –

Source: 2008–2010 (revised 3/12) and 2011–2012 SAMHSA National Surveys on Drug Use and Health (NSDUHs)

95 % CI confidence interval, N/A variable not included in model, OR odds ratio, SUD substance use disorder

Matern Child Health J

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lower income, unemployment, and poverty) had the highest

prevalence of past month SPD.

Perhaps the most important finding was that pregnant

women with past month SPD were less likely than post-

partum women to report MHT, even after we controlled for

potential confounders. These findings were similar to those

identified in the National Epidemiologic Survey on Alco-

hol and Related Conditions, which found that pregnant

women with psychiatric disorders were less likely to seek

MHT than were nonpregnant women with psychiatric

disorders [23]. This may be a result of the lack of screening

for mental health problems among obstetrical patients. For

example, Birndorf et al. [35] reported that among patients

in one obstetrical practice, only 30 % of women who

screened positive for depression had discussed the symp-

toms with their ob-gyn, although 82 % said they would be

willing to discuss the symptoms and all of them reported

that they would seek MHT if their ob-gyn referred them.

Other studies have reported similarly low rates of problem

recognition and treatment receipt [36, 37]. Examination of

the correlates of MHT among pregnant and postpartum

women with past month SPD indicated that non-Hispanic

black women and women of an ‘‘other’’ race, unmarried

women, and uninsured women had particularly low rates of

MHT although all women may benefit from screening.

There are a few limitations to this study that should be

acknowledged. First, NSDUH is a cross-sectional survey

and not appropriate for the individual course of psycho-

logical distress analyses. In NSDUH, individuals who may

have had elevated psychological distress in their first tri-

mester are not the same women with elevated distress in

the postpartum period. Thus, it is not possible to compare

the pattern of prevalence estimates directly to studies that

provide longitudinal analyses of distress over time.

Second, sample size limitations made comparisons of

each trimester and postpartum period imprecise, as evi-

denced by large confidence intervals. Moreover, the small

sample size necessitated combining pregnant and post-

partum women with SPD to examine correlates of MHT.

Although pregnant and postpartum women with SPD were

similar in most characteristics, there were a few significant

differences. Compared to pregnant women with SPD,

postpartum women with SPD were older, more likely to be

married, and less likely to have had a past year alcohol or

drug use disorder (results not shown). Future research with

a larger sample is needed to determine if there are unique

correlates of MHT in pregnant or postpartum women with

SPD.

Third, misclassification is a concern. NSDUH collects

data on past month psychological distress; therefore,

women who have just entered a new period (e.g., 1 week

into the first postpartum period) may be reporting distress

from the prior period. This is more likely to affect esti-

mates using the shorter time increments (trimester and

Fig. 2 Prevalence (and 95 % CI) of MHT among women with SPD, aged 18–44, by pregnancy or postpartum status: annual averages, National

Surveys on Drug Use and Health, 2008–2012. Source 2008–2010 (revised 3/12) and 2011–2012 SAMHSA NSDUHs

Matern Child Health J

123

postpartum months) than the combined pregnant and

postpartum categories. In addition, measures of MHT

reflect any treatment in the past year, so a woman who

reported MHT may have received that treatment before,

during, or after pregnancy. A similar misclassification can

be seen with past year alcohol use disorders and illicit drug

use. Pregnant women who report past year drug use may be

reporting use prior to pregnancy, whereas postpartum

women reporting use are almost assuredly reporting use

during pregnancy or the postpartum period. Additional

misclassification may have arisen if women who put

newborns up for adoption were classified as being non-

pregnant/nonpostpartum. However, results from the

National Survey of Family Growth suggest that voluntary

placement of infants is rare [38]. Women who experienced

miscarriages, abortions, or infant deaths also may have

been misclassified as being nonpregnant/nonpostpartum

women.

In these analyses, response bias may have arisen if

women close to delivery were less likely to participate in

NSDUH. Evaluation of the unweighted frequency of

response for each month of pregnancy suggests that this

may have occurred: 13.2 % of pregnant women reported

being in their eighth month of pregnancy, whereas only

7.1 % of pregnant women were in their ninth month. If past

month SPD or past year MHT in pregnant or postpartum

women was associated with this potential nonresponse, the

direction and magnitude of this bias would be unknown.

Even if this potential response bias were not related to SPD

or MHT, it would still result in decreased statistical power.

Despite these limitations, the prevalence of past month

SPD in pregnant and postpartum women is not negligible.

An estimated 4.8 % of pregnant women and 5.4 % of

postpartum women had SPD; this equates to an estimated

111,000 pregnant and 234,000 postpartum women annu-

ally. Moreover, of the women with SPD, more than half did

not receive MHT in the past year. Pregnancy and the

postpartum period are times of increased contact with

medical professionals, providing opportunities for mental

health screening and referral to treatment. Some practitio-

ners have recommended [39, 40] and implemented [41, 42]

screening and intervention programs; however, the results

of this study suggest that there is room for improvement.

Acknowledgments The authors would like to acknowledge Chris-

tine Ulbricht for her contributions in the early design phase of this

project. The National Survey on Drug Use and Health (NSDUH) is

funded by the Substance Abuse and Mental Health Services Admin-

istration (SAMHSA), Center for Behavioral Health Statistics and

Quality (CBHSQ). This study was funded and approved under

SAMHSA Contract No. 284-2010-0003C, Project No. 0212800.002,

which was supported by funding from the National Institute of Mental

Health (NIMH). The views expressed in this manuscript do not

necessarily represent the views of the National Institutes of Health or

the Federal Government.

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