2025 Theses Doctoral

In the Shadow of Postpartum Depression: An Investigation of the Heterogeneity of Perinatal Psychopathology During the COVID-19 Pandemic

Alhomaizi, Alaa

Background:
Beginning in March 2020, pregnant, laboring, and postpartum women were dealing with the challenges inherent to the perinatal period against the backdrop of a global pandemic. By the beginning of 2022, as the risk of the Omicron wave loomed and the pandemic had closed on its second year, there was a cohort of women who had their entire pregnancy and some, if not almost all, of their postpartum period during the pandemic. When the crisis changed from acute to chronic, it became imperative to investigate how the prolonged nature of the pandemic affected perinatal women, and importantly, understand the nature and manifestation of perinatal symptomatology experienced by these women. Prior to the pandemic, there was growing scientific evidence of the heterogeneous nature of maternal psychopathology during the perinatal period. Therefore, it was important to investigate whether the same pattern of heterogeneity will underlie the perinatal mental health outcomes during the COVID-19 pandemic, and to see whether this heterogeneity can be organized into phenotypic patterns of symptom expression. The overall aim of our study was to investigate the heterogeneity of perinatal psychopathology during the COVID-19 pandemic by identifying and describing symptom profiles, and to identify the correlates of symptom profile membership. Additionally, a secondary aim of our study was an in-depth investigation of the role and manifestation of irritability, an understudied and overlooked area in perinatal research, as it related to perinatal psychopathology during the COVID-19 pandemic.

Method:
This study utilized cross-sectional data (N = 630) from the Pregnancy, Postpartum, and Parenting During a Pandemic Study (P-4) online survey, which included scales measuring demographic information, psychosocial risk factors, maternal emotional well-being and functioning, and COVID-19-related life events. First, we used confirmatory factor analysis and exploratory factor analysis to determine the factor structures of the Center for Epidemiologic Studies Depression Scale (CES-D) and Perinatal Anxiety Screening Scale (PASS) to create factor-based subscales. We then used these factor-based subscales as indicators for a latent class analysis (LCA) to identify symptom profiles (i.e., classes) of perinatal psychopathology during the COVID-19 pandemic. Afterwards, we investigated correlates that were associated with class membership, including demographic variables, psychosocial predictors, onset of symptoms, COVID-19-related life events, and COVID-19 changes to the perinatal period. We utilized analysis of variance (ANOVA) with the continuous variables and multinomial logistic regression with the categorical variables. Then, we characterized irritability in our sample and established its clinical relevance. We examined irritability’s relationship with depression, anxiety, maternal functioning, and suicidality via Spearman correlations and linear regressions. We also examined psychosocial predictors of irritability via stepwise regression. Finally, we used ANOVA to examine the differences in the levels of irritability symptoms, including state and trait irritability, as well as irritability’s impact on various domains (e.g., family relationships), across the symptom profiles.

Results:
Four depression factors from the CES-D and five anxiety factors from the PASS were used as factor-based indicators in the LCA. We determined that a five-class solution best fit the data. We identified three quantitative classes that primarily differed from each other in symptom severity, and we labeled them Non-Clinical (n = 268), Average (n = 167), and Severe Psychopathology (n = 60). We also identified two qualitative classes, which did not differ from each other in overall symptom severity, but instead, exhibited a set of unique elevations that suggested distinct phenotypic symptom expressions. We labeled the two classes Interpersonally Sensitive (n = 104) and Postpartum Obsessive-Compulsive Symptoms (OCS) (n = 31). Generally, the correlates of class membership revealed that greater risk factors, and lower protective factors, were associated with greater symptom severity. However, there were some key exceptions to this pattern, as evidenced by the qualitative classes with similar severity levels, such as: 1) the Interpersonally Sensitive class reported the second highest rate of suicidal ideation; and 2) participants who endorsed a history of psychiatric symptoms or baby blues had the highest likelihood of belonging to the Postpartum OCS class, compared to the Non-Clinical class. As for irritability, it was associated with higher clinical depression and anxiety, as well as lower maternal functioning and higher suicidal ideation in the overall sample. Finally, we found that classes with greater symptom severity reported higher rates of irritability, and those with similar symptom severity levels (i.e., Interpersonally Sensitive and Postpartum OCS) reported comparable irritability levels. However, while overall irritability did not differ between the two qualitative classes, there was a trend towards state irritability being more relevant for the Postpartum OCS class and trait irritability being more relevant for the Interpersonally Sensitive class.

Conclusions:
Our results revealed significant heterogeneity in phenotypic symptom expression among perinatal women during the COVID-19 pandemic. All classes reported symptoms of depression and anxiety, underscoring that comorbid symptoms are the norm, not the exception, for this population. Critically, since two classes (i.e., Interpersonally Sensitive and Postpartum OCS) had similar levels of global severity, but exhibited distinct overall symptom profiles, it underscored the importance of using key symptom elevations, not total scores, to guide identification and treatment of perinatal psychopathology. Finally, irritability was a marker of distress and related to global severity, and as such, should be incorporated within the detection and treatment of perinatal psychopathology. Future research should examine whether the diverse symptom profiles identified in this study can be replicated outside the context of a global stressor, such as the COVID-19 pandemic.