Antenatal depression predicts depression in adolescent offspring:
Prospective longitudinal community-based study
Susan Pawlbya,⁎, Dale F. Hayb, Deborah Sharpc, Cerith S. Watersb, Veronica O'Keanea
aInstitute of Psychiatry, King's College London, UK
bCardiff University, Wales, UK
cUniversity of Bristol, UK
Received 9 April 2008; received in revised form 24 May 2008; accepted 24 May 2008
Available online 7 July 2008
Background: Depression is familial. Evidence shows that untreated postnatal depression is associated with adverse outcomes for
the child. Few studies have traced prospectively the course of maternal depression through pregnancy, the postnatal period and the
following 16 years in relation to adolescent offspring depression.
Method: The sample was recruited from two general practice antenatal clinics. Of 151 mother–child dyads followed from pregnancy
to 16 years, information on the course of maternal depression and on depression in adolescent offspring was available for 127 (84%).
morethan one episode.Athirdof thewomenwere depressed inpregnancy(41/124).Over halfof thesewomen (23/41)had consulted
(18/127) of the adolescent offspring were diagnosed with a depressive disorder at 16 years. Every depressed adolescent had been
for offspring not so exposed. The effect of antenatal depression was mediated by repeated exposure.
Limitations: The number of study participants is small and limited to an inner-city population. Only depression spectrum diagnoses
in the adolescent offspring have been considered.
Conclusions: Detection of depression in pregnancy identifies mothers at risk of further depressive episodes and a group of children
who are at risk of depression in adolescence.
© 2008 Elsevier B.V. All rights reserved.
Keywords: Adolescent depression; Antenatal depression; Prospective study
Longitudinal studies have consistently shown that
children of depressed parents have a two- to threefold
higher risk of developing a depressive disorder in their
lifetime than children of parents who have never been
depressed (Beardslee et al., 1998; Weissman et al., 2006).
Recently, such studies have begun to investigate the
importance of factors such as the timing, severity and
chronic nature of maternal depression in determining the
outcome for adolescent offspring, and in explaining the
intergenerational transmission of depression (Hammen
and Brennan, 2003). Particular attention has been paid to
Journal of Affective Disorders 113 (2009) 236–243
⁎Corresponding author. Section of Perinatal Psychiatry, PO Box 71,
Institute of Psychiatry, King's College London, De Crespigny Park,
E-mail address: email@example.com (S. Pawlby).
0165-0327/$ - see front matter © 2008 Elsevier B.V. All rights reserved.
the developmentof psychiatric disorderin the offspringof
mothers suffering from depression in the postnatal period
(Abbott et al., 2004; Murray et al., 1999; Halligan et al.,
2007). However, few longitudinal studies have begun in
pregnancy, despite the fact that pregnancy potentially
depressivesymptoms inwomen(O'Keane,2006) andthat
puerperium (Josefsson et al., 2001; Evans et al., 2001).
Where studies have taken into account the antenatal
period, they have either relied on the retrospective
reporting of events occurring many years before (in
of self-reported anxiety and depressive symptoms in
pregnancy, rather than of a diagnosis obtained through
psychiatric interview, on children's emotional and beha-
vioural outcomes in early and middle childhood (Allen
et al., 1998; Luoma et al., 2001; O'Connor et al., 2002).
We studied maternal mood during pregnancy and the
postnatal period in a community cohort of women
recruited during the antenatal period, and followed them
up, along with their offspring, for 16 years. We have
previously reported findings up to 11 years on this cohort
(Sharp et al., 1995; Hay et al., 2001, 2003). We
episodes of maternal depression in pregnancy, the
postnatal period and in subsequent years and tested for
16 to ascertain the timing of maternal depression with the
greatest predictive value for adolescent depression.
155 women, representing 87% of a random sample of
antenatal patients in two general practices in South
London, provided information on their mental health
during pregnancy and the postnatal period. 151 (97%) of
these women were followed up beyond the child's first
year. We assessed mother–child dyads at 4, 11 and
16 years of age. Methods have previously been described
(Sharp et al., 1995; Hay et al., 2001, 2003).
Based on the 2001/2002 data collected throughout
communities that we studied ranked on the 6th and 11th
percentiles, where a lower rank indicates greater
deprivation. Compared to national norms, the sample
had a higher proportion of working class families and
families from ethnic minorities (ONS, 2006). The
mothers' IQs (N=136) ranged from 69 to 127 but with
a below average mean of 90.60 (SD=13.40).
when the index child was 16 years old. Eight families had
moved abroad or could not be traced, and 6 families were
not willing to participate at 16 years. However, in 10
families, insufficient information on the adolescent's
emotional state at 16 years was obtained for a clinical
diagnosis to be made. In 7 cases the Strength and
Difficulties Questionnaires (Goodman, 1997) were com-
pletedbut not the interview, 2adolescents were living with
their fathers and 1 independently and the mothers had no
contact. There were no significant differences in the
mother-rated total difficulties score or the emotional
problems score for those with and without full interview
families, 82% of the original sample of 155. Demographic
characteristics of this sample are presented in Table 1.
2.2. Chronology and assessments
2.2.1. Pregnancy and the first postnatal year
Two academic GPs, one from each practice, inter-
viewed mothers from each other's practice, twice during
pregnancy, between 14 and 20 weeks and at 36 weeks,
and twice during the first postnatal year, at 3 and at
12 months. Socio-demographic data and information on
Characteristics of the sample (N=127)a
Mother's age at birth
Marital status at birth
M=26.0, SD=5.1 (range, 16 to 43)
63% married, 28% cohabiting, 9% single
89% working class
72% white British, 6% white, non-British,
22% other (Caribbean, African, South
Asian, East Asian, mixed)
72% basic qualifications,
14% further education
57% married (87% to biological father)
14% cohabiting (35% to biological father)
29% single parent household
51% two biological parents
42% biological mother
5% biological father
2% no biological parent (other relative
(N=1), independently (N=1), under
supervision of the Social Services (N=1))
M=16.3 years, SD=.25 (range, 16 to 17.3)
at age 16
Parent in household
Child's birth order
46% 5 or more GCSEs A* to C
aNs vary slightly (120–127) because of missing data on some
bGoldthorpe and Hope, 1974.
237S. Pawlby et al. / Journal of Affective Disorders 113 (2009) 236–243
events during pregnancy and surrounding the birth were
collected. At each interview, details of the women's past
contact with their GP for mental health problems were
recorded and an assessment was made of the women's
current mental state over the past two weeks, using the
Clinical Interview Schedule (CIS), to generate ICD-9
diagnoses (Goldberg et al., 1970). The overall agreement
of the reported symptoms on the CIS from the tape-
recorded interviews, given as a weighted kappa coeffi-
2.2.2. 4th, 11th and 16th birthdays
We visited families at home when the children were
approaching 4 years and at 11 and 16 years. At each time
point, mothers provided socio-demographic informa-
tion, current and retrospective to the last visit, to one of
two research psychologists who was unaware of the
information collected at previous visits. Diagnoses of
maternal major depression (probable and definite),
minor depression (definite), and intermittent depression,
both current and retrospective to the last assessment,
were made according to Research Diagnostic Criteria
(RDC). We used the lifetime version of the Schedule for
Affective Disorders and Schizophrenia (SADS-L —
Spitzer et al., 1978). All interviews were tape-recorded.
Diagnoses were made on the basis of the content of
these interviews, by a senior research psychologist and a
psychiatrist who had not participated in the interviews.
In tape-recorded interviews at 16 years, mothers and
children were independently asked, each by a different
researcher, about the child's psychological problems,
using the Child and Adolescent Psychiatric Assessment
(Angold et al., 1995). The CAPA is a psychiatric
interview for children that elicits information about
symptoms contributing to a wide range of DSM-IV
diagnoses. A three-month ‘primary period’ is used rather
than a longer period, because shorter periods are
Diagnoses and symptom scales were generated by
computer algorithms. Separate algorithms are available
for child, parent and ‘combined reports,’ where a
symptom is regarded as being present if either the
parent or child reports it. In this paper, we report DSM-
IV diagnoses of major depressive disorder, dysthymic
disorder and depression not otherwise specified, based
on combined reports. Diagnoses are made with
reference to the functional impairment or incapacities
section of the CAPA, which relates the symptoms to the
adolescent's ability to function at a developmentally
appropriate level in relationships with family, peers, and
teachers, and in activities at school, home and in the
community. A test–retest reliability study of the CAPA
resulted in kappa coefficients of .85 for dysthymia and
.90 for major depression (Angold and Costello, 1995).
The intraclass correlation coefficient for judgements of
impairments and incapacities was .76. The construct
validity of CAPA diagnoses is supported by a wide
range of findings (Angold and Costello, 2000).
All phases of the study were approved by the Ethics
Committee of the Institute of Psychiatry, King's College
London (at 16 years, Study No. 259/01). After complete
description of the study to the participants, written
informed consent was obtained from both mothers and
their adolescent offspring.
2.4. Statistical analysis
Maternal depression in pregnancy was rated as being
present if an ICD diagnosis was given at the second and/
or third trimester interviews. The current and ‘retro-
spective to last visit’ data were used to assess the rates of
maternal depression over four subsequent developmen-
tal time periods. In the first postnatal year, a diagnosis of
maternal depression was given if the mother had a
current ICD diagnosis at 3 months and/or at 12 months.
Where data were missing, retrospective RDC diagnoses
in early childhood (1–4 years), middle childhood (4–
11 years) and adolescence (11–16 years). The develop-
mental time period in which each childwas first exposed
to maternal depression was determined. The number of
periods (ranging from 0 to 5) during which the offspring
were exposed to maternal depression depended on the
number of developmental periods in which mothers
reported having had a depressive episode.
Outcome measures in each group (depressed versus
non-depressed) were compared using the χ2test with
odds ratios and 95% confidence intervals and, where
appropriate, the nonparametric Mann–Whitney U test.
Logistic regression analyses determined the effects of
potential confounding variables and mediators on the
adolescent outcome measure.
3.1. Maternal depression from pregnancy to 16 years
Of the 127 women, 82 (64.6%) had had at least one
238S. Pawlby et al. / Journal of Affective Disorders 113 (2009) 236–243
index child's 16th birthday. The point prevalence of
depression1was higher at both time points in pregnancy
and at 3 months postpartum than at any of the other time
20% in the secondtrimester of pregnancy, 21% inthe third
trimester of pregnancy, 21% at 3 months after the birth,
18% at 1 year, 14% at 4 years, 6% at 11 years and 2% at
prevalence of maternal depression between the develop-
mental periods from pregnancy to 16 years (Table 2), and
there was substantial continuity for individual women,
from pregnancy to the adolescent period (N=119, kappa
coefficient=.30, pb.001). Of the depressed women,
63.4% experienced more than one episode.
The incidence of depression among the women was
health problems at some point in their lives before
previously sought help from a GP were three times more
likely than women who had not sought help to become
depressed in pregnancy (N=124, χ2(1)=7.65, pb.01,
women who were depressed during the child's lifetime
were initially identified as depressed in pregnancy.
Almost all (89.7%) of the mothers who were depressed
in pregnancy became depressed again, having a nine-fold
χ2(1)=18.74, pb.001, OR=9.20 [CI 2.99 to 28.29]).
periods over the 16 years following the child's birth than
mothers who were not depressed in pregnancy (N=121,
Mann–Whitney U=812.5, z=−4.74, pb.001). Only 4
mothers were depressed in pregnancy alone. There were
no significant differences between mothers who were
depressed and those who werewellin pregnancy interms
of maternal age, marital status in pregnancy, social class,
level of education, parity, ethnicity or gender of the
3.2. Adolescent depression at 16 years
Eighteen (14.2%) of the 127 adolescents, 14 (20.3%)
girls and 4 (6.9%) boys, were diagnosed as having a
depressive disorder according to DSM-IV criteria in the
3-month period immediately preceding the interview at
16 years. Ten adolescents had a major depressive
disorder, in all cases superimposed on dysthymia. A
further 6 adolescents had a diagnosis of depression not
otherwise specified, 3 of which were superimposed on
dysthymia. Two adolescents had a diagnosis of dysthy-
mia. A third (6/18) of the depressed adolescents (4 girls
and 2 boys) had planned or made suicide attempts. Girls
were more likely than boys to be diagnosed with a
depressive disorder (N=127, χ2(1)=4.65, pb.05,
OR=3.44 [CI 1.06 to 11.10]). There was no significant
difference in the mother's age, parity, ethnicity, social
class, educational level, or marital status at birth or at
16 years, or in the ethnicity or educational attainment of
the depressed adolescents, compared with those who
were not depressed. Those who were depressed were
more likely not to live with both biological parents
(N=127, χ2(1)=4.60, pb.05, OR=3.18 [CI 1.06 to
3.3. Timing of maternal depression and adolescent
Just over a fifth (20.7%) of the adolescents who had
been exposed to maternal depression had a depressive
exposed to maternal depression. Adolescent offspring
who had been exposed to maternal depression at some
point since conception were significantly more likely to
be depressed at 16 years than adolescent offspring who
had never been exposed (N=123, χ2(1)=9.86, pb.01).
This was not explained by the mother's retrospective
history of mental health problems before becoming
pregnant with the index child.
Sixty-five percent (11/17) of adolescents with depres-
sion were initially exposed in the antenatal period. There
1The Ns vary slightly (range 120 to 127, except at 4 years when
N=112) because of missing data.
Period prevalence and incidence of maternal depression from pregnancy
through the following 16 years (N=127)a
% (N)% (N)
Timing of maternal depression
Prior to index pregnancy
1st postnatal year
Early childhood (years 1 to 4)
Middle childhood (years 4 to 11)
Adolescence (years 11 to 16)
aNs vary slightly between 122 and 127 because of missing data.
2The mother's complete history of depression during the child's
lifetime was unavailable for one of the 18 depressed adolescents as
she had left the UK when her son was aged 10 to 13 and he had been
looked after by a guardian.
239S. Pawlby et al. / Journal of Affective Disorders 113 (2009) 236–243
was a 4.7-fold greater odds of adolescent depression
among the 16-year-olds who had been exposed to
maternal antenatal depression than for offspring who
the child to maternal depression during each of the other
developmental periods in the child's lifetime was not
associated with adolescent offspring depression (Fig. 1).
Adolescent depression was also associated with a greater
number of periods of exposure to maternal depression
(N=123, U=425.5, z=−3.59, pb.001). Depressed
adolescents were exposed to over twice as many time
periods of maternal depression (mean=2.82 [SD, 1.59]
versus 1.31 [SD, 1.40]) as non-depressed adolescents.
Logistic regression showed that initial exposure to
maternal depression in the antenatal period was no longer
itself a significant predictor when account was taken of
the chronic nature of the mother's depression (Table 3).
was a strong predictor of depression in the adolescent
offspring, mediated by subsequent periods of depression
depressed at 16 years increased by 1.74 (1.12 to 2.71) for
every period of maternal depression from pregnancy to
The family variable associated with adolescent
depression – not living with two biological parents at
16 years – was also associated with maternal depression
in pregnancy. Logistic regression showed that maternal
depression in pregnancy remained a significant pre-
dictor of adolescent depression when accounting for
family structure at 16 years, whereas family structure
did not (Table 4).
The strong familial association between maternal and
adolescent depression, already well-documented (Lieb
was replicated in our study. All of the 16-year-old
adolescents who became depressed had been exposed to
maternal depression at some point in their lives.
Pregnancy was found to be the time period when the
greatest number of offspring was initially exposed to
maternal depression, and children who were exposed
not exposed to become depressed at 16 years. For the
Fig. 1. Timing of child's first exposure to maternal depression and 16-year-old adolescent depression.3
Predictors of depression in adolescent offspring
Logistic regression model with maternal depression in pregnancy and
total number of depressive episodes (N=121)
95% CI for EXP (B)
B (SD) Lower EXP
Depression in pregnancy
Total no of depressive time
periods (range 0–5, pregnancy
to 16 years)***
.59 (.73) .43
.55 (.23) 1.12
Note R2=.12 (Cox and Snell) .22 (Nagelkerke); Model χ2(2)=15.47,
3Adolescent offspring who were first exposed to maternal
depression in utero were over 4× as likely as those not then exposed
to be depressed at 16 years (N=124, χ2(1)=8.91, pb.01, OR=4.71
[CI 1.60 to 13.86]). Initial exposure at other time periods did not
predict adolescent outcome.
240S. Pawlby et al. / Journal of Affective Disorders 113 (2009) 236–243
women in our study, episodes of depression in pregnancy
children's lifetimes. Episodes in pregnancy showed
strong continuity with those that occurred outside it.
Women who were depressed during pregnancy were
almost 10 times as likely as those not depressed in
show that it was the effect of maternal depression in
pregnancy per se that predicted adolescent depression,
they did show that the majority of children who were
depressed at 16 years had initially been exposed in the
antenatal period and were at risk of further exposure
because ofthe stronglikelihoodofrecurrenceofmaternal
depression later in the child's life.
This longitudinal, prospective, community-based
study found that during the 16-year period following
their index pregnancy, almost two-thirds of mothers
reported episodes of depression that were of sufficient
severity to require care from a GP or to impair their daily
functioning. Over half of these women had first been
identified as being depressed in pregnancy. Several
factors may explain these high rates of depression. First,
the two communities were selected on the basis that a
high level of socio-economic deprivation would identify
high prevalence and persistence of depression (Ostler
et al., 2001). Second, women in the childbearing and
early childrearing years have been shown to have high
rates of anxiety and depression (Cox et al., 1993). In
addition, frequent assessment of mothers' mental health
by clinical interview in a cohort study with a very high
retention rate may have unveiled a truer picture of the
cumulative prevalence of depression from pregnancy
over the following 16 years than figures calculated from
one wave studies or from primary care statistics.
Evidence from the NICE report (2004) on the detection
and treatment of depression in the UK showed that the
majority of people with depression never consulted a
doctor. Therefore documented rates of the prevalence of
the disease are likely to be an underestimate of the actual
number of sufferers. Similar high cumulative prevalence
rates of depression and of other psychiatric disorders are
emerging from other prospective longitudinal cohort
studies (Angst et al., 2005; Moffitt et al., 2007a,b). The
14% point prevalence rate of adolescent depression at
16 years found in our study was similar to that reported
in the Dunedin, New Zealand study, where peak
incidence was between the ages of 15 and 18 (Hankin
et al., 1998). A recent report revealing that less than a
third of parents of children aged 5 to 16 years with
emotional disorders in England and Scotland had sought
help from the primary health care services suggests that
official statistics underestimate the number of adoles-
cents suffering from depression (Green et al., 2004).
This study has many strengths. It is a community-
based study, begun in pregnancy with mothers and their
offspring followed through 16 years. Assessments of
maternal mental health were made using structured
clinical interviews on seven occasions throughout this
time period and diagnoses were made after discussion
with a psychiatrist. We identified mainly cases of
moderate depression typically found in the community.
Our retention rate was extremely high. In pregnancy and
the postnatal period, the interviews were carried out by a
doctor unfamiliar with the patient group. Interviewers at
each further phase of the study were blind to the
participants' psychiatric histories.
However the study should also be interpreted in the
context of some potentially important limitations. Many
of the depressed women in the sample suffered from an
episode in pregnancy. Mothers' symptoms of affect
disorder in pregnancy are often associated with
unhealthy behaviours (e.g., smoking cigarettes or
drinking alcohol), and may disrupt the developing
HPA axis in the foetus (see O'Keane, 2006). However,
in the present sample, only four women who were
depressed in pregnancy had not become depressed
again, and so our study did not have adequate statistical
power to disentangle antenatal influences from the
effects of cumulative exposure to maternal depression.
Secondly, the number of study participants is small and
limited to a city population with high levels of social and
economic deprivation. It is therefore difficult to general-
ize the findings presented here to other socio-economic
groups and geographical locations. However, the rates
of adolescent depression are comparable with those of
other much larger studies (Hankin et al., 1998). A third
limitation is that no consideration is given here to
paternal mental health. Fourthly, assessments of the
mothers' mental health prior to pregnancy were not
made with standardized instruments. Compared to the
Predictors of depression in adolescent offspring
Logistic regression model with depression in pregnancy and family
structure at 16 years (N=124)
95% CI for EXP(B)
B(SD) LowerEXP (B) Upper
1.40 (.56) 1.344.0412.18
.83 (.59).722.29 7.24
Note R2=.08 (Cox and Snell) .15 (Nagelkerke); Model χ2(2)=10.43,
241S. Pawlby et al. / Journal of Affective Disorders 113 (2009) 236–243
rigorous way in which the mothers' mental health was
assessed at all other time points, this represents a
limitation. A further limitation is that only maternal
diagnoses of depression are considered in relation to
adolescent depression. Comorbid cases have been
included but not considered independently. In addition,
only depression spectrum diagnoses in the adolescent
offspring have been considered here.
In this particular prospective analysis we have shown
that adolescent offspring depression is predicted by
maternal depression in pregnancy. Identification of
depression in pregnancy has several advantages. Preg-
nancy is a period in a woman's life when she is likely to
have frequent contact with health care professionals.
Early detection of maternal depression may accelerate
to further recurrent depressive episodes in the postnatal
period and later in her child's lifetime. Until recently,
research has focused on the detection of maternal
depression in the postnatal period and its effect on the
child's development. However, evidence that depression
in pregnancy is more common than in the postpartum is
The recent NICE guidance on antenatal and postnatal
mental health is now advocating asking pregnant women
care services (NICE, 2007). Detection and treatment of
depression in pregnancy would seem to be important in
preventing mothers suffering a lifetime of depression and
in reducing the intergenerational transmission of depres-
sion. We know that the outlook for adolescents with
depression is poor and that they themselves are at risk of
further episodes in adulthood (Harrington et al., 1990;
Weissman et al., 2006).
Role of funding source
Funding for this study was provided by the Medical Research
Council U.K. Project Grant Nos. G89292999N and G9539876N
awarded to the late Professor Channi Kumar, Dr Deborah Sharp and
Dr Dale Hay, the Psychiatry Research Trust and the South West G.P.
the collection, analysis and interpretation of data; in the writing of the
report; and in the decision to submit the paper for publication.
Conflict of interest
All authors declare that they have no conflicts of interest.
The authors thank Helen Allen, Susie Hales, Alice
Mills, Ph.D., Natasha Newbery, Anne O'Herlihy, Gesine
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