The association between adverse childhood experiences and perinatal depression symptom trajectories

Background Having a history of adverse childhood experiences (ACEs) is associated with an increased risk of treatment-resistant depression in the general population. Whether this relationship is true in the perinatal context is unknown. Objective(s) To examine the association between ACEs and trajectories of antenatal and postpartum depression in people enrolled in a perinatal collaborative care program for mental health care. Study design This retrospective cohort study included all pregnant and postpartum people who were referred to and enrolled in a perinatal collaborative care program for mental health care and delivered at a single quaternary care institution between March 2016 and March 2021. Individuals referred to the collaborative care program were linked with a care manager and had access to evidence-based mental health treatment such as psychiatric consult, pharmacotherapy, and psychotherapy. All individuals enrolled in the collaborative care program received ACE screens at intake. A score of > 3 on the validated Adverse Childhood Experiences Questionnaire defines a high ACE score. Depression symptom monitoring occurred via electronic PHQ-9 screening every 2-4 weeks and escalation of care is recommended for those without evidence of improvement. Antenatal depression trajectories were determined by comparing the earliest available prenatal PHQ-9 score closest to the time of referral to collaborative care to the latest PHQ-9 score before delivery. Postpartum trajectories were determined by comparing the earliest postpartum PHQ-9 score after delivery to the latest score before 12 weeks postpartum. Depression trajectories were categorized as improved, stable, or worsened based on whether the PHQ-9 scores changed by at least two standard deviations (i.e., 5 points on PHQ-9 scale). Bivariable and multivariable analyses were performed. Results Of the 1,270 people who met inclusion criteria, 294 (23.1%) reported a high ACE score. Those with a high ACE score were more likely to experience a worsened antenatal depression trajectory when compared to those with a low ACE score (10.3% vs 4.3%, p=0.008). This association persisted after adjusting for potential confounders (aOR 2.39, 95% CI 1.05-5.46). There was no significant difference in postpartum depression trajectories between those with a high vs. low ACE score. Conclusion(s) Having a high ACE score is associated with a worsened trajectory of antenatal depression for those enrolled in a collaborative care program. Given its high prevalence, future research should evaluate effective modalities of perinatal depression prevention and treatment specific for pregnant people with a history of adverse childhood experiences.