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Rate and Predictors of Postpartum Depression in a 22-Year Follow-Up of a Cohort of Earthquake Survivors in Armenia

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Rate and Predictors of Postpartum Depression in a 22-Year Follow-Up of a Cohort of Earthquake Survivors in Armenia Arch Womens Ment Health DOI 10.1007/s00737-013-0404-5 ORIGINAL ARTICLE Rate and predictors of postpartum depression in a 22-year follow-up of a cohort of earthquake survivors in Armenia Anahit Demirchyan & Diana Petrosyan & Haroutune K. Armenian Received: 28 September 2013 /Accepted: 26 December 2013 # Springer-Verlag Wien 2014 Abstract Disasters have serious long-term impact on mental significantly related to the outcome (OR=3.75). The rate of health for those exposed. The aim of this study was to identify postpartum depression in this 22-year cohort was similar to predictors of postpartum depression among survivors of the that among the Armenian general population. Earthquake 1988 devastating earthquake in Armenia. A nested case–con- exposure was not related to postpartum depression, indicating trol design was applied to investigate postpartum depression that the impact of disaster-related trauma diminishes over in a large-scale cohort of survivors followed between 1990 time. The identified predictors provided evidence to develop and 2012. From an original group of 725 adults who were interventions targeting groups of women most prone to post- assessed for psychopathology in 1990, 146 women reported partum depression under such circumstances. having a delivery after the earthquake and were included in this study. Women with postpartum depression were identified Keywords Postpartum depression . Predictors . Earthquake using Edinburgh Postnatal Depression Scale. A logistic re- survivors . Armenia gression model was fitted to identify the predictors of post- partum depression. Of the 146 women, 19 (13.0 %) had postpartum depression. Five independent predictors of post- Introduction partum depression were identified: number of woman’sstress- ful life events (odds ratio (OR)=2.06), her prior history of Psychopathological morbidity is one of the important areas of postpartum depression (OR=16.98), delivering sick/dead ne- investigation among populations exposed to natural and man- onate (OR=13.65), poor living standards during the post- made disasters, as there is compelling evidence suggesting earthquake decade (OR=5.77), and perceiving oneself reli- that disasters have adverse short- and long-term impact on able in 1990 (OR=0.24). Anxiety in 1990 was marginally mental health status of those exposed, particularly in terms of increasing the rates of post-traumatic stress disorder and de- pression (Armenian et al. 2002; Rubonis and Bickman 1991; A. Demirchyan (*) North et al. 2004;Armenianetal.2000). A meta-analysis of School of Public Health, American University of Armenia, 50 post-disaster psychopathology studies (Rubonis and 40 Marshal Baghramian Avenue, Yerevan 0019, Armenia Bickman 1991) indicates that between 7 and 40 % of the e-mail: [email protected] subjects exposed to disasters show some form of psychopa- D. Petrosyan thology and that anxiety is the most prevalent among them Global Fund Projects Coordinating Team, Ministry of Health, followed by phobia, alcohol impairment, depression, drug Government Building #3, Yerevan 0010, Armenia impairment, and stress. The disaster effect-size in this meta- e-mail: [email protected] analysis was estimated to be 0.174, meaning that a 17.4 % H. K. Armenian increase in the prevalence rates of baseline psychopathology Department of Epidemiology, Fielding could be expected as a result of disaster exposure, and the School of Public Health, UCLA, effect-size was higher in the case of multiple causalities of 650 Charles E. Young Dr. S, 16-035 Center for Health Sciences, Los Angeles, CA 90095-1772, USA stress and among victims of natural as opposed to man-made e-mail: [email protected] disasters (Rubonis and Bickman 1991). A. Demirchyan et al. A prospective study examining the development of general Over the past two decades, the population of Armenia has psychopathology among traumatized adolescents over a 5–8- faced several crises: the devastating earthquake of Spitak in year period after the disaster showed that compared to unex- 1988, the collapse of the Soviet Union in 1991, the war in posed controls, the relative risk for developing any affective or Nagorno-Karabakh during 1988–1994, and the long-lasting anxiety disorder, including late-onset depression, was signif- economic crisis due to the difficult transition to a market icantly higher only among those survivors who had developed economy aggravated by the blockade of the country applied posttraumatic stress disorder (PTSD) and that recovery from by neighboring Turkey and Azerbaijan. In a population-based PTSD was associated with recovery from other mental disor- cohort study following the 1988 earthquake in Armenia, ders (Bolton et al. 2000). A substantial evidence suggests that Armenian et al. (2002) found that depression was a major PTSD, depression, and trauma-specific phobia are usually public health problem under such circumstances. In their highly intertwined in disaster survivors and that the preva- study, half of the adult participants from the earthquake region lence of all these post-disaster mental health conditions sig- were identified as fulfilling the criteria for major depression nificantly diminishes over time (Rubonis and Bickman 1991; after 2 years following the disaster. According to this study, Bolton et al. 2000;Meewisseetal.2011). The intensity of female gender, the severity of earthquake-related destruction, traumatic exposure and other sources of life and childhood and the extent of material loss experienced by the family were stress, as well as low socioeconomic status, are found to be independent risk factors for depression among the earthquake predictive for post-disaster psychopathology (Meewisse et al. survivors (Armenian et al. 2002). A prospective study which 2011;Quetal.2012;Harvilleetal.2009b, 2010;O’Hara and followed the Spitak earthquake survivors for 4.5 years have Swain 1996; Beck 2001;Norrisetal.2002). demonstrated that the traumatized adults are at high risk of Studies have shown that women are more prone to post- developing not only severe but chronic posttraumatic stress disaster psychopathology than men (Rubonis and Bickman reactions that are related to chronic anxiety and depression 1991;Norrisetal.2002). According to some evidence, preg- (Goenjian et al. 2000). nant and postpartum women may be especially vulnerable to In 2006, the prevalence of depressive symptoms among the mental health consequences of disasters, and developing general adult female population of Armenia was estimated to be PTSD poses these women at higher risk of developing one as high as 53.0 % (Demirchyan et al. 2011). A recent study of the most common complications of childbearing—postpar- carried out among Yerevan residents revealed a 14.4 % preva- tum depression (Onoye et al. 2009; Bromet and Litcher-Kelly lence of postpartum depression symptoms, which was not much 2002; Benyakar and Collazo 2005). different from that in other societies (Petrosyan et al. 2011). Although longitudinal and epidemiological studies have The current nested case–control study used a unique op- yielded varying rates of postpartum depression depending on portunity provided by a large-scale cohort study—Post-earth- diagnostic instruments used and study methodology applied, a quake Psychopathological Investigation (PEPSI)—which meta-analysis of 59 studies reported an average prevalence of followed the 1988 Armenian (Spitak) earthquake survivors 13 %, with most cases starting in the first 3 months postpartum prospectively for over 22 years (Armenian et al. 1997, 1998). (McCoy et al. 2006;O’Hara and Swain 1996). The conse- The cohort study made possible investigating the effect of a quences on the quality of life of the suffering women and her number of important baseline characteristics of female survi- family members, as well as the adverse impact on infant’s vors of the earthquake on their odds of developing postpartum growth and development, place the postpartum depression in depression years after the disaster. The objective of this nested line with other major public health concerns (Wisner et al. case–control study was to identify the rate and some risk 2006;Surkanetal.2011; Cooper and Murray 1997;Austin factors of postpartum depression among women exposed to et al. 2007). the earthquake adversities and the difficulties of post- Despite the high prevalence, the cause of postpartum de- earthquake period. The study also aimed to investigate wheth- pression remains unclear with extensive research conducted to er the disaster had a long-term impact on women’s post- determine the magnitude of the relationship between different partum mental health. risk factors and its development. The evidence suggests that the predictors of postpartum depression include prenatal de- pression, childcare stress, life stress, low level of social sup- Methods port, prenatal anxiety, low level of satisfaction with marital relationship and single marital status, history of previous Participants The study participants were selected from the depression and postpartum depression, low self-esteem, low PEPSI cohort. The latter was initiated in 1990 to investigate socioeconomic status, poor delivery outcome, and unplanned/ the long-term health consequences of the 1988 Spitak earth- unwanted pregnancy (O’Hara and Swain 1996;Beck2001; quake. The cohort consisted of all employees of the healthcare Fisher et al. 2012; Warner et al. 1996;Surkanetal.2008; services in the earthquake zone and their family members— Cooper and Murray 1995). 32,743 individuals in total, whose
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