Lifetime costs of perinatal anxiety and depression

Abstract

Anxiety and depression are common among women during pregnancy and the year after birth. The consequences, both for the women themselves and for their children, can be considerable and last for many years. This study focuses on the economic consequences, aiming to estimate the total costs and health-related quality of life losses over the lifetime of mothers and their children.
Method
A pathway or decision modelling approach was employed, based on data from previous studies. Systematic and pragmatic literature reviews were conducted to identify evidence of impacts of perinatal anxiety and depression on mothers and their children.
Results
The present value of total lifetime costs of perinatal depression (anxiety) was £75,728 (£34,811) per woman with condition. If prevalence estimates were applied the respective cost of perinatal anxiety and depression combined was about £8,500 per woman giving birth; for the United Kingdom, the aggregated costs were £6.6 billion. The majority of the costs related to adverse impacts on children and almost a fifth were borne by the public sector.
Limitations The method was exploratory in nature, based on a diverse range of literature and encountered important data gaps.
Conclusions
Findings suggest the need to allocate more resources to support women with perinatal mental illness. More research is required to understand the type of interventions that can reduce long-term negative effects for both mothers and
offspring.

Full text

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Lifetime costs of perinatal anxiety and depression
Authors:
Annette Bauer, Research Fellow, Personal Social Services Research Unit, London School of
Economics and Political Science, London, UK
Martin Knapp, Director, Personal Social Services Research Unit, London School of
Economics and Political Science, London, UK
Michael Parsonage, Chief Economist, Centre for Mental Health, London, UK
Corresponding author:
Annette Bauer, a.bauer@lse.ac.uk, Personal Social Services Research Unit (PSSRU),
London School of Economics and Political Science, Houghton Street, London, WC2A 2AE,
Tel: 020-7852 Ext 3784
ABSTRACT
Background
Anxiety and depression are common among women during pregnancy and the year
after birth. The consequences, both for the women themselves and for their children,
can be considerable and last for many years. This study focuses on the economic
consequences, aiming to estimate the total costs and health-related quality of life
losses over the lifetime of mothers and their children.
Method
A pathway or decision modelling approach was employed, based on data from
previous studies. Systematic and pragmatic literature reviews were conducted to
identify evidence of impacts of perinatal anxiety and depression on mothers and their
children.
Results
The present value of total lifetime costs of perinatal depression (anxiety) was
£75,728 (£34,811) per woman with condition. If prevalence estimates were applied
the respective cost of perinatal anxiety and depression combined was about £8,500
per woman giving birth; for the United Kingdom, the aggregated costs were £6.6
billion. The majority of the costs related to adverse impacts on children and almost a
fifth were borne by the public sector.
Limitations
The method was exploratory in nature, based on a diverse range of literature and
encountered important data gaps.
Conclusions
Findings suggest the need to allocate more resources to support women with
perinatal mental illness. More research is required to understand the type of
interventions that can reduce long-term negative effects for both mothers and
offspring.
KEYWORDS
Perinatal depression; perinatal anxiety; child; costs; economic impact; lifetime;
decision modelling

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Abbreviations
1
1 Introduction
The World Health Organization recognises perinatal mental health as a major public
health issue; at least one in ten women has a serious mental health problem during
pregnancy or in the year after birth (WHO, 2008; 2014). The impact on mothers can
be considerable during the perinatal period because of new emotional, social,
financial and physical challenges. Additionally, the pre- and postnatal periods have
significant impacts on future physical, mental and cognitive development of offspring:
children of mothers with perinatal mental illness are exposed to higher risks of low
birth-weight, reduced child growth, intellectual, behavioural and socio-emotional
problems (Hay et al., 2010; Surkan et al., 2011; Conroy et al., 2012; Kingston and
Tough, 2014; Pearson et al., 2013a,b; O’Donnell et al., 2014).
We focus on perinatal depression and anxiety, the most prevalent conditions during
the perinatal period. Despite their high prevalence they are often overlooked by
health professionals: the likelihood of women seeking help or being identified is
below 50% even in well-funded health systems (Vesga-López et al., 2008; Ko et al.,
2012; Howard et al., 2014). Of those who are clinically detected, only 10-15% get
effective treatment (Woolhouse et al., 2009; Goodman and Tyer-Viola, 2010; Gavin
et al., 2015). The impacts of perinatal mental illness on mothers and children are
many; here we focus on the
wide-ranging and intergenerational economic
consequences.
2 METHODS
In summary, our approach was to consider the life-course from the perspective of
both mother and child. We used decision-analytic modelling to determine incremental
costs associated with adverse effects, discounted to present value at time of birth.
Modelling helps to utilise data from many sources, attaching costs and outcomes to
events that happen with estimated probabilities. Our modelling reflected the
additional risks of adverse child developments for offspring exposed to perinatal
depression and anxiety, and their associated public sector costs, health-related
quality of life and productivity losses. Data were taken from previous studies following
a literature review. We extracted effect sizes of child development problems and
transformed them into additional risk differences applied to different ages. Costs of
adverse effects of perinatal depression and anxiety were calculated from a societal
perspective, including costs to government and individuals.
1
ALSPAC = Avon Longitudinal Study of Parents and Children, ED = Education, HRQoL =
Health-related quality of life, HSC = Health and social care, OOP = Out-of-pocket
expenditure, NHS = National Health Service, p = probability, PL = Productivity loss, pp. =
percentage points, PTB = Pre-term birth, RD = Risk difference, UC = Unpaid care, UK =
United Kingdom, wks. = weeks, yrs. = years

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2.1 Literature review
Systematic searches were conducted to identify studies measuring the impact of
perinatal anxiety and depression for mothers and children, including adverse birth
and child development outcomes, health-related quality of life, loss of life (infanticide
and suicide), productivity, unpaid care, victim costs of crime and public service use.
Searches were performed on PsycINFO, CINAHL, Global Health, SocINDEX, Social
Care Online, covering the period January 2000 to May 2014.
Additional pragmatic searches were carried out to fill evidence gaps, including
searches on Google, Google Scholar and national websites. Websites included those
of the National Collaboration for Women’s and Children’s Health, the National
Collaborating Centre for Mental Health and the Avon Longitudinal Study of Parents
and Children. We also checked bibliographies of relevant articles identified in the
systematic searches.
Our searches focused mainly on UK evidence but considered studies from other
high-income countries. Studies that did not apply appropriate statistical analysis
(such as adjusting for history of mental illness and other perinatal risk factors) were
excluded.
Information retrieved from studies included: effect sizes, service use patterns, costs,
health utilities, prevalence and natural course of conditions. For studies measuring
the effect of perinatal anxiety or depression on child outcomes, we removed those
not using quantifiable, standardised measures or measuring only intermediate
outcomes without evidence of economic consequences; the latter could only be
decided based on our knowledge about economic studies of outcomes, so this
process was iterative with the search for economic studies.
2.2 Path/decision modelling
Based on the evidence on adverse effects of perinatal anxiety and depression we
developed four models reflecting impacts of the two conditions on mothers and their
offspring.
First, from published prevalence figures at different stages during pregnancy and
after birth we derived mean probabilities for mothers developing antenatal and
postnatal anxiety or depression. From general remission rates for depression and
anxiety we estimated annual probabilities for mothers continuing to have the
condition after the first year. We assumed (conservatively) that all mothers had
recovered from their initial episode within ten years.
To avoid double-counting the impact of co-occurring perinatal depression and anxiety
on mothers, we derived a probability of developing antenatal anxiety without co-
morbid depression based on prevalence for ante- and postnatal anxiety and the scale
of co-existence between perinatal anxiety and depression. This meant that some
costs which related to comorbid perinatal anxiety and depression were captured
under the costs of perinatal depression. This step was not necessary for the impact
on children because studies were available that measured the impact of each of the
two conditions separately from each other.
Since our aim was to estimate the present value of lifetime costs, we discounted
costs and HRQoL after the first year postpartum to the time of birth at an annual rate
of 3.5% measured in real terms. Earnings were assumed to increase at 2% a year

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over and above the general rate of inflation. Cost data were adjusted where
necessary to 2012/13 prices.
2.2.1 Measuring the impact on mothers
We measured impacts on mothers based on data on derived additional (annual) risk
of developing ante- or postnatal depression or anxiety and continuing to have
symptoms after the perinatal period, multiplied by public sector costs, HRQoL
impairments and productivity losses. We distinguished between costs during the
perinatal period and in subsequent years. Based on data from longitudinal studies
identified during the searches and national averages we assumed mean age for
women at childbirth of 32 years, mean remaining life expectancy of 44 years and
retirement from employment at 65.
Costs of additional health and social care were taken from studies measuring
additional service use and costs for women with perinatal depression or anxiety or
individuals with remitted and non-remitted depression or anxiety in the general adult
population. For studies which measured service use patterns but not costs, we took
unit costs from Curtis (2013) and NHS Reference costs (DH 2013).
Unless the incremental health disutility values had been already evaluated by
controlled trials, HRQoL impairments were calculated by taking the difference
between health utility values for individuals with the relevant conditions and mean
quality of life in the general female population (Ara and Barzie, 2011). Health disutility
was applied to years in ill-health and multiplied by a willingness-to-pay value. We
assumed a willingness-to-pay value of £25,000 for a health-related quality-adjusted
life year, reflecting the mid-point of the £20,000 to £30,000 range used by National
Institute of Health and Care Excellence (Appleby et al., 2007). We estimated costs
attached to an increased risk of suicide during the subsequent years based on
national suicide statistics for depression in the general population and costs of life
lost (Harker, 2011; ONS, 2014). For a whole life lost through suicide or infanticide,
we applied the ‘value of a prevented fatality’, estimated at £1,722,000 per case,
which is used in UK government policy analysis (DH, 2010).
We calculated productivity losses for mothers based on probabilities that women
would be in full- or part-time employment after giving birth, multiplied by reduced
working days for someone with concurrent or remitted depression or anxiety (ONS,
2005, 2013a; DWP, 2010; Plaisier et al., 2010). We applied lost work days for
concurrent depression or anxiety to the annual probabilities of mothers to have
depression or anxiety linked to the initial perinatal condition; we applied lost work
days for remitted depression or anxiety to the probabilities of mothers not having any
further episodes linked to the perinatal condition. To value annual changes in
productivity following a human capital approach we applied mean weekly wage rates
to time away from work from national statistics (ONS, 2013b).
2.2.2 Measuring the impact on children
We identified birth and child outcomes for which there was evidence of adverse
effects linked to perinatal anxiety or depression such as pre-term birth, infant death,
emotional, intellectual and conduct problems. Effects measured at different ages
were transformed into annual additional risks measured in percentage points,
reflecting an incremental perspective in which only the additional impact associated
with a condition was assessed.

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For each link between maternal perinatal anxiety or depression and adverse birth or
child outcomes we extracted information on effect sizes from studies identified in our
search. If there was more than one relevant previous study we used the most
conservative effect size. From the relative effect sizes (odds ratios, relative risks) and
baseline risks in published studies that measured the negative impact on children we
calculated absolute risk reductions as the difference in observed risk for an outcome
occurring in the exposed versus the non-exposed group. Some absolute risk
difference estimates were available from our own work (Bauer et al., 2015). We
applied prevalence data from the literature.
We assumed that annual additional risks between measured time points were
constant; for example, if data for child intellectual problems was available at 6 years
and again at 11 years we applied effect sizes found at 6 years to the period 6 to 11
years. To model the persistence of childhood conditions, including progression from
infancy to childhood and childhood to adolescence and adulthood, we took data from
surveys and longitudinal studies, assuming that those conditions stopped at age 65.
The next step was to assign costs to adverse birth and child outcomes at different
ages, the calculation depending on the nature of the outcome and previous evidence.
For some outcomes long-term costs were available from previous studies. For other
outcomes, the associated short-term, annual costs of public services were available
from the literature so we applied those after adjustment to 2012/13 prices to years for
which there was a proven effect, discounted to time of birth. For attaching values to
public service use, health-related quality of life impairments and productivity we
applied the same approach as when valuing impact on mothers. In addition, we
estimated costs of infant death based on risk data of infant mortality in mothers with
perinatal depression or anxiety and average infant mortality data in the general UK
population (ONS, 2011).
3 Findings
3.1 Impact on mothers
3.1.1 Perinatal depression
Parameters used for estimating the impact of perinatal depression on mothers and
details of their derivation are shown in Table 1.
Mean probabilities for developing depression were 10.7% during pregnancy and
7.4% in the year after childbirth; annual probabilities for persistent depression linked
to the original episode were 0.09% from the first to the fifth year, and 0.052%
thereafter up to tenth year postpartum.
Present values of lifetime costs per woman with perinatal depression were £1,688 for
health and social care, £3,028 for productivity and £18,158 for health-related quality
of life losses. Estimates were based on mean probabilities for developing perinatal
depression and for persistence in subsequent years, published costs of health and
social care and health disutility (specific to the perinatal period and general adult

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population ones for subsequent years), work days lost for women with current or
remitted depression.
There was insufficient data to estimate costs of suicide linked to the perinatal phase.
However, evidence was available that allowed us to derive the additional risk of
suicide attributable to depression in the general UK population and we applied this to
the additional risk of subsequent episodes of depression linked to the perinatal
phase. The present value of lost life was £277 per woman with perinatal depression.
3.1.2 Perinatal anxiety
Present values of lifetime costs per mother with perinatal anxiety were £4,320 for
health and social care, £5,499 for productivity losses, £10,975 for health-related
quality of life losses. Estimates were based on mean probabilities of developing
perinatal anxiety (without co-existing depression), its persistence in subsequent
years, annual costs of health and social care and health disutility for people with
anxiety disorder in the general population. Work days lost were calculated
distinguishing again between remitted and non-remitted anxiety. Data on costs,
health disutility and work days lost all referred to the general adult population with
anxiety. Details of the parameters used for estimating the lifetime costs of perinatal
anxiety for mothers are shown in Table 2. We did not identify UK-relevant evidence
on the link between anxiety disorder, during the perinatal phase or subsequent years,
and suicide. Potential life years lost due to anxiety-caused suicide were thus not
valued.
3.2 Impact on children
3.2.1 Perinatal depression
There was strong evidence – including from meta-analysis and two UK longitudinal
studies - on links between ante- or postnatal depression and the following birth and
child or adolescent outcomes until age 16: pre-term birth, infant death, teacher-
reported special educational needs and leaving school without qualifications,
emotional problems and conduct problems (Sanderson et al., 2002; Howard et al.,
2007; Halligan et al., 2007; Grote et al., 2010; Murray et al., 2010; Bauer et al.,
2015). Studies controlled for a wide range of covariates such as previous maternal
depression, co-existing perinatal anxiety and socio-demographic characteristics.
Details of parameters applied in the analysis of lifetime costs for the impact of
perinatal depression on children are presented in Table 3.
3.2.1.1 Pre-term birth
The present value of costs of pre-term birth - based on proportions of extremely (<28
weeks) versus otherwise pre-term birth (28 to 36 weeks.) - were £974 per child
exposed to antenatal depression for health and social care, £20 for education, £418
for health-related quality of life losses, £22 for productivity losses and £14 for costs of
parents’ out-of-pocket expenditure. These estimates were based on additional risks
for a child exposed to antenatal depression being born extremely pre-term of 0.1 pp.
and otherwise pre-term of 2.54 pp. While costs of health and social care, education,
out-of-pocket expenditure and productivity losses could be taken from existing UK
long-term estimates, health-related quality of life losses between ages 5 and 18

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required additional calculations. Health disutility data were available from the
literature for children born extremely pre-term. For children born otherwise pre-term
we used health disutility experienced by children with moderate cognitive impairment.
All values and details of parameters are shown in Table 3.
3.2.1.2 Infant death
Costs for lost life at the time of birth were £22,157 per woman with depression. This
was based on the mean probability of postnatal depression and additional risk to
sudden death for infants of mothers who suffered from postnatal depression (Table
3).
3.2.1.3 Emotional problems
Lifetime costs of child emotional problems per woman with perinatal depression
were: £1,020 for health and social care, £558 for education, £4,936 for health-related
quality of life losses and £2,379 for productivity losses. This was based on mean
probabilities of child exposure to perinatal depression and additional risks of
development and persistence of emotional problems, published annual public sector
costs and health disutility data for children with emotional problems (5-16 yrs) and
adults with depression (17-65 yrs.). For the calculation of adulthood costs we applied
a mean duration of persistent emotional depression of 16 years and assumed an
equal distribution of costs over the lifetime. Details of parameters used in the
calculations are in Table 3.
The risk of a child developing emotional problems differed depending on whether or
not the mother experienced subsequent episodes of depression linked to the original
postnatal episode. The additional risk for children exposed to perinatal maternal
depression but not to subsequent episodes of developing emotional problems was 5
pp whilst the additional risk linked to perinatal depression occurring with subsequent
episodes was as high as 16 pp (age 11). We used those figures for the years 11 to
16; for the years 5 to 11 we applied an adjusted, reduced risk reflecting the course of
child emotional problems.
3.2.1.4 Conduct problems
Costs of child conduct problems per woman with perinatal depression were £837 for
health and social care, £1,974 for criminal justice, £1,797 for productivity losses,
£3,396 for health-related quality of life losses, and £7,446 for crime victim costs.
Estimates were based on probabilities of exposure to perinatal depression and an
additional risk to develop conduct problems, proportions of children with conduct
problems with and without the severity of a disorder (Colman et al., 2009) and
existing lifetime costs of conduct problems with and without the severity of a disorder
(Table 3).
3.2.1.5 Special educational needs and leaving school without qualifications
The present value of costs for additional education was £3,166, linked to the
additional risk of requiring special education. The present value of productivity losses
was £1,463, because of lower earnings from leaving school without qualification,

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taken from previous work in this area (Bauer et al., 2015). Similar figures had been
found by Murray et al. (2010).
3.2.2 Perinatal anxiety
Although less strong than for perinatal depression, there was evidence of a link
between perinatal anxiety and adverse birth and child outcomes. The majority of
papers analysed the link between ante- or postnatal anxiety and adverse child
outcomes based on data from the Avon Longitudinal Study of Parents and Children
(ALSPAC). Outcomes that were affected included pre-term birth, emotional and
conduct problems and chronic abdominal pain (O’Connor et al., 2002; Ramchandani
et al., 2006; Orr et al., 2007; O’Donnell et al., 2014). Studies controlled for a wide
range of variables such as history of mental illness, co-existing perinatal depression
and various socio-demographic characteristics.
3.2.2.1 Pre-term birth
The costs of pre-term birth per woman with perinatal anxiety were £2,435 for health
and social care, £13 for education, £54 for productivity losses, £1,044 for health-
related quality of life and £34 for parental out-of-pocket expenditure. These were
based on an additional risk of pre-term birth which varied from 5.5pp to 13.3pp
depending on the severity of the mother’s anxiety. The proportions of pre-term births
defined as extremely or otherwise pre-term and their associated costs were the same
as used in relation to perinatal depression.
3.2.2.2 Emotional problems
Costs of child emotional problems per woman with antenatal anxiety were £273 for
health and social care, £176 or education, £440 for productivity losses, £535 for
health-related quality of life losses. These estimates were based on an additional risk
of child emotional problems of 1.7 pp. and on the same parameters as used to
estimate the costs of emotional problems attributable to perinatal depression during
childhood (age 5 to 16) and adulthood (age 17 to 65).
3.2.2.3 Conduct problems
For child conduct problems, the costs at present value per woman with antenatal
anxiety were £236 for health and social care, £558 for criminal justice, £508 for
productivity losses, £960 for health-related quality of life losses, and £2,105 for crime
victim costs. These were based on an additional risk of conduct problems of 3.4 pp
and the same parameters as used to measure the lifetime costs of conduct problems
attributable to perinatal depression.
3.2.2.4 Chronic abdominal pain
The costs of chronic abdominal pain in children per woman with perinatal anxiety
were £1,531 for health and social care, £140 for education, £736 for productivity
losses, £347 for out-of-pocket expenditure and £1,892 for unpaid care. These
estimates were based on the additional risk that children exposed to perinatal anxiety

9
would develop chronic abdominal pain of 4 pp (5 to 16 years). Annual cost data were
available from the literature for children in treatment for chronic abdominal pain.
Conservatively, we reduced costs of health and social care by half, assuming that
only 50% with chronic abdominal pain accessed such treatment.
3.3 Total impact on mothers and children
Findings on costs are summarized in Table 5. Aggregated present values of lifetime
costs per woman with condition were £75,728 for perinatal depression and £34,811
for perinatal anxiety. If mean prevalence estimates were applied, the respective
aggregated cost of perinatal anxiety and depression was about £8,500 per woman
giving birth. For 778,805 live births in UK in 2013, the costs amounted to £6.6 billion.
Sixty percent of the costs related to the adverse impact on children. Almost a fifth of
the total costs were borne by the public sector, with the bulk of these falling to NHS
and social care.
4 Discussion
4.1 Summary of main findings
The lifetime impact of perinatal anxiety and depression was substantial and the
majority of the costs related to the impact on offspring. The findings showed that
those adverse birth and child development outcomes project negative long-lasting
consequences in terms of the individual’s morbidity (physical and mental ill health),
quality of life and career prospects over a lifetime, and possibly even carried over to
another, third generation. Although the majority of costs were those to individuals and
society, there are still substantial costs carried by the public sector, in particular the
NHS and social care.
4.2 Comparison with the literature
Our study took a lifetime perspective, which allowed us to capture a comprehensive
set of consequences as they happen at different life stages from birth to infancy,
childhood, adolescence and adulthood. As it is the case for cost-of-illness studies
generally, the few studies which have been carried out in the maternal and child
health field measure the yearly direct costs based on prevalence and health care
expenditure or resource use data (Saha and Gerdtham, 2013). It is thus not
appropriate to compare the costs we identified with estimates from other studies.
4.3 Implications
Our study shows the overall impact of perinatal depression and anxiety but does not
explore the economic case for intervention. A number of evaluations have shown
interventions in this area to be cost-effective; they focus on measuring the short-term
outcomes of mothers (Morrell et al., 2009; Bauer et al., 2011; Dukhovny et al., 2013;
Sockol et al., 2013). The (cost-) effectiveness of interventions in reducing the long-
term impacts of perinatal mental illness on children and mothers are largely

10
unknown. Research is needed to investigate which types of interventions during the
perinatal period can improve long-term child development outcomes and their cost
implications (Howard et al., 2014; Thornicroft and Patel 2014). However, studies of
this type are expensive and, of course, attribution becomes a bigger issue the longer
the time period.
Therefore - in the absence of this knowledge – analysis of existing longitudinal data
on long-term outcomes and costs for different individuals affected by perinatal mental
illness can be helpful. This includes further analysis of the role of other perinatal risk
factors and mediating variables such as breastfeeding and infant attachment (Hahn-
Holbrook et al., 2013; Borra et al., 2014). Research should address a limitation of
current studies which only analyse the association between a single perinatal
condition and one or two child development outcomes; studies need to take
adequate account of comorbidities and accumulating effects on children. Further
research should also consider the impact of father’s depression which correlates with
maternal perinatal mental illness and – as suggested by recent studies – has its own
effect on adverse child development (Paulson et al., 2006; Ramchandani et al., 2008;
Goodman et al., 2008; Edoka et al., 2011).
4.4 Limitations
The exploratory nature of our method has a number of limitations that need to be
considered when interpreting our findings. To capture a broad set of economic
consequences we worked with a range of literature but still faced data gaps. To
address data shortages we took additional steps that could not be planned in
advance, including pragmatic literature searches. For example, whilst some studies
established incremental data, this was not always the case and we thus had to look
for comparison data (usually national averages). A standardised and consistent
approach to estimate cost impact was handicapped by different types of data sources
and study designs. Due to the large number of studies and evolving evidence base
we were not able to carry out detailed quality assessments and instead applied
pragmatic selection criteria. Because papers did not always provide full statistical
details (such as means and confidence intervals), we were unable to carry out
substantive sensitivity analysis. Instead, in order to increase the robustness of the
results, our approach and the assumptions were generally conservative.
A lack of data required certain assumptions. For example, data was not always
available for the specific condition and we used approximate values. A lack of data
also meant that not all adverse outcomes could be included in the analysis; this
included suicide linked to anxiety (without co-existing depression) and HRQoL loss
linked to chronic abdominal pain. Whilst it is possible and likely that childhood
conditions and their economic consequences overlap, we did not have the data to
account for this in our analysis.
Finally, the analysis was concerned with averages across different groups and thus
did not shed light on subgroups that should be targeted when considering how to
best use available resources.
5. Conclusion
This is the first study that investigates the costs of perinatal depression and anxiety
from a lifetime perspective, taking into account the impact of these conditions on both

11
mothers and their children. The analysis shows that the overall cost of perinatal
mental illness is very large, suggesting the importance of this area as a major (public)
health priority, and requiring much greater attention than it has been given to date.
Further research is required to understand which interventions can reduce the long-
term effects on mothers and children.
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