Journal of Affective Disorders 255 (2019) 27–40

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Prevalence, onset and course of anxiety disorders during pregnancy: A T

systematic review and meta analysis
Kirupamani Viswasama,b, , Guy D. Eslickb,c, Vladan Starcevicb
⁎

a
Department of Psychiatry, Nepean Hospital, Sydney/Penrith, NSW, Australia
b
University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Nepean Clinical School, Sydney/Penrith, NSW, Australia
c
The Whiteley-Martin Research Centre, Discipline of Surgery, Sydney/Penrith, NSW, Australia

ARTICLE INFO ABSTRACT

Keywords: Background: Anxiety disorders during pregnancy are associated with various adverse outcomes. Previous re-
Anxiety views of anxiety disorders during pregnancy have methodological limitations and were conducted without a
Pregnancy meta-analysis. The present study is a systematic review and meta-analysis of the published research on the
Prevalence prevalence, onset and course of all anxiety disorders during pregnancy plus obsessive-compulsive disorder
Onset
(OCD) and posttraumatic stress disorder.
Course
Methods: A comprehensive literature search was performed on a wide range of databases. A random effects
model was used for the meta-analysis.
Results: Thirty-six studies were included. Prevalence rates of anxiety disorders during pregnancy varied con-
siderably. The pooled prevalence rate of each disorder during pregnancy was 3%, except for specific phobia,
where it was 6%. Between 13% and 39% of pregnant OCD women had the onset of OCD during pregnancy, and
this occurred mainly in the 2nd trimester. The onset of panic disorder (PD) was more common in the 1st and 2nd
trimesters of pregnancy.
Limitations: Different designs of the included studies, as well as different assessment tools and assessment times
during pregnancy and the paucity of studies of the onset and course, preclude definitive conclusions.
Conclusions: Anxiety disorders are common during pregnancy. Unlike prevalence rates of other anxiety disorders
during pregnancy, prevalence rates of PD and OCD during pregnancy were higher than their lifetime prevalence
rates in women in the general population. The onset of OCD during pregnancy is not rare and the course of PD
and OCD during pregnancy is highly variable. These findings suggest that pregnancy may be a specific risk factor
for the occurrence and/or exacerbation of PD and OCD and underscore the importance of their early diagnosis
and management.

1. Introduction
Pregnancy is a sensitive time for women, with significant physio-
logical and psychological changes occurring during this period. It is,
therefore, not unusual for pregnant women to have concerns about
various aspects of their pregnancy. However, some women are affected
by their anxiety to the extent that it interferes with their everyday life,
and studies have reported that a considerable proportion of women
suffer from significant anxiety symptoms during pregnancy
(Vythilingum, 2008). While some women experience an anxiety dis-
order for the first time during pregnancy, those with pre-existing an-
xiety disorders may be more likely to experience changes in their
mental state during pregnancy (Martini et al., 2015).
Anxiety disorders experienced during pregnancy often cause
maternal distress and may pose a significant risk for postnatal disorders
and affect the unborn child (Vythilingum, 2008). This includes adverse
outcomes such as pre-term delivery, bonding issues and abnormal child
development (Martini et al., 2015; Milgrom et al., 2008; Sutter-Daley
et al., 2004). For example, women with untreated panic disorder (PD)
during pregnancy were found to be at risk of delivering babies at an
earlier gestational age, with a markedly lower birth weight (Uguz et al.,
2018).
Recent studies about prevalence of mental health issues during
pregnancy included anxiety symptoms and disorders, but the findings
reported for the specific anxiety disorders have varied in the reviews
and have often been combined with findings pertaining to the post-
partum period. For example, a review by Leach et al. (2015) mainly
reported on the prevalence of anxiety disorders and risk factors during

⁎
Corresponding author at: Department of Psychiatry, Nepean Hospital, P. O. Box 63, Penrith, NSW 2751, Australia.
E-mail address: mani.viswasam@health.nsw.gov.au (K. Viswasam).

https://doi.org/10.1016/j.jad.2019.05.016
Received 28 March 2019; Received in revised form 8 May 2019; Accepted 10 May 2019
Available online 11 May 2019
0165-0327/ Crown Copyright © 2019 Published by Elsevier B.V. All rights reserved.
K. Viswasam, et al.
postpartum, with only 2 studies reporting on the specific anxiety dis-
orders in the 1st trimester of pregnancy. Estimated prevalence rates in
these 2 studies were 0.4% and 4.0% for PD, 1.5% and 17.2% for
agoraphobia, 1.6% and 3.4% for obsessive-compulsive disorder (OCD),
1.9% and 10.5% for generalized anxiety disorder (GAD), 3.8% and
4.6% for social anxiety disorder, 0.7% and 1.7% for posttraumatic
stress disorder (PTSD) and 10.7% for specific phobia (based on one
study). Goodman et al. (2014) reviewed prevalence, course and out-
come of anxiety disorders during pregnancy and reported the following
prevalence rates: 0.2%–5.7% for PD (based on 12 studies), 0.9% -
17.2% for agoraphobia (based on 5 studies), 0.2%–5.2% for OCD (based
on 11 studies), 0.0%–10.5% for GAD (based on 11 studies), 0.4%–6.4%
for social anxiety disorder (based on 10 studies), 3.2%–19.9% for spe-
cific phobia (based on 7 studies) and 0.0%–7.9% for PTSD (based on 11
studies). A review by Ross and McLean (2006) included studies of
prevalence, onset and course of anxiety disorders (excluding agor-
aphobia, social anxiety disorder and specific phobia) mainly during
postpartum, with 11 studies reporting these data during pregnancy.
They found prevalence rates of PD of 2.0% during pregnancy (based on
one study) and 1.3%–1.4% during the 3rd trimester of pregnancy
(based on 2 studies). Prevalence rates of OCD ranged from 0.2% to
1.2% during the 3rd trimester of pregnancy (based on 2 studies), while
the prevalence rate of GAD during the 3rd trimester was 8.5% (based on
one study). Finally, prevalence rates of PTSD were 7.7% during preg-
nancy (based on one study) and ranged between 0.0% and 8.1% during
the 3rd trimester (based on 3 studies).
These diverse prevalence rates of anxiety disorders reported in re-
views published thus far may be due to differences in the number of
studies included, various study designs and sample sizes, different study
populations, various types of assessment measures and settings in
which the studies were conducted and variability in assessment points.
Only one review focused on the onset of anxiety disorders in the
perinatal period (Ross and McLean, 2006), with its findings pertaining
to the postpartum period. The only exception was OCD, with 4 studies
reporting a new onset during pregnancy in 13.1%–39.0% of pregnant
women with OCD and one study reporting that 6.0% experienced an
onset of OCD during the 3rd trimester of pregnancy.
The course of anxiety disorders during pregnancy was first reviewed
by Ross and McLean (2006) who found a few studies of the trajectory of
PD and OCD. Inconsistent patterns were reported for the course of PD
during pregnancy and no change in OCD symptoms was found in 2
studies. A review by Goodman et al. (2014) reported similar variability
in the course of PD during pregnancy, while finding no changes in OCD
symptoms in 44%−83% of women with pre-existing OCD, worsening of
OCD symptoms in 8%−46.1% and improvement in OCD symptoms in
8%−23%.
Limitations of these reviews include sparse data available and ex-
clusion of vulnerable subpopulations who might have had a greater risk
of developing anxiety disorders, such as adolescent pregnant women
and those who were immigrants, refugees or had a history of stillbirth
or hyperemesis. Furthermore, some reviews (e.g., Ross and
McLean, 2006) failed to include all anxiety disorders.
The aim of the present study was to conduct a systematic review and
meta-analysis of the published research on the prevalence, onset and
course of all anxiety disorders during pregnancy. This includes GAD,
OCD, PD with or without agoraphobia, social anxiety disorder, specific
phobia and PTSD. We included all anxiety disorders in the review be-
cause we intended to examine whether there were any appreciable
differences between them. Considering that only one article reviewed
the prevalence, onset and course of anxiety disorders during pregnancy
and that it was published more than a decade ago (Ross and
McLean, 2006), our intention was also to provide an updated review of
the literature in this domain.
Recent classification systems such as the Fifth Edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5;
American Psychiatric Association, 2013) include as anxiety disorders
28
Journal of Affective Disorders 255 (2019) 27–40
only PD, agoraphobia, GAD, social anxiety disorder and specific phobia.
However, we decided to also search for studies of OCD and PTSD be-
cause these conditions have important links with anxiety disorders and
were classified among the anxiety disorders prior to DSM-5. Findings of
this review are expected to shed more light on the prevalence, onset and
course of anxiety disorders and related conditions (i.e., OCD and PTSD)
during pregnancy, with implications for clinical practice.
2. Methods
2.1. Literature search
We followed the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). A com-
prehensive literature search was performed in February 2019 on a wide
range of databases including Google Scholar, MEDLINE, EMBASE,
PsychINFO, PubMed and ProQuest. Combinations of the following
search terms were used: pregnancy, perinatal, prenatal, anxiety disorders,
panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder,
generalized anxiety disorder, social anxiety disorder, social phobia, specific
phobia, onset, course, trajectory and prevalence. The reference lists of
relevant articles were also searched for appropriate studies. No search
for unpublished literature was performed.
2.2. Inclusion and exclusion criteria
We included studies that met the following criteria:
1 Full-length articles published in English without date restriction.
2 Articles reporting on the prevalence, onset and/or course of various
anxiety disorders (including OCD and PTSD) during pregnancy, re-
gardless of any history of abuse or trauma.
The following were our exclusion criteria:
1 Articles reporting solely on the treatment of anxiety disorders
during pregnancy.
2 Articles that do not report on the specific anxiety disorders, i.e.,
those that report on anxiety disorders as a group.
3 Single case reports, abstracts, review articles and commentaries to
articles.
4 Articles that include participants with pre-existing psychotic dis-
orders.
5 Articles reporting solely on the findings in the postpartum period.
6 Articles that do not present pregnancy and postpartum findings se-
parately.
2.3. Data extraction
The following data were extracted from articles included in the
review: publication year, study characteristics, sample size, study de-
sign, assessment points, measures used, number of assessments during
pregnancy, onset, course and prevalence rates.
2.4. Statistical analyses
Pooled event rates and 95% confidence intervals were calculated for
each of the anxiety disorders reported during pregnancy using a
random effects model (DerSimonian and Laird, 1986). We tested het-
erogeneity using the I2 statistic, which represents the percentage of the
total variability across studies that is due to heterogeneity (Higgins and
Thompson, 2002). The I2 scores of 25, 50 and 75% represent low,
moderate and substantial heterogeneity, respectively (Higgins and
Thompson, 2002). We quantified publication bias using Egger's re-
gression model with the effect of bias assessed using the fail-safe
number method (Egger et al., 1997). The fail-safe number was the
K. Viswasam, et al.
Fig. 1. Flowchart of selection process.
number of studies that we would need to have missed for our observed
result to be nullified to statistical non-significance at the p < 0.05 level.
All analyses were performed with Comprehensive Meta-Analysis soft-
ware v 3.0 (Biostat Inc, Englewood, NJ 2014).
3. Results
Fig. 1 presents the PRISMA flow chart, showing that of 130 articles
identified through the searches, 36 met our inclusion criteria. Fig. 1 also
shows reasons for excluding articles.
3.1. Panic disorder with or without agoraphobia
The characteristics and results of the 19 studies examining various
aspects of PD during pregnancy are summarised in Table 1. Prevalence
rates of PD during pregnancy were reported in 12 studies and ranged
from 0.4% to 7.5% (Adewuya et al., 2006; Borri et al., 2008; Farais
et al., 2013; Giardinelli et al., 2012; Guler et al., 2008; Marchesi et al.,
2014; Rogal et al., 2007; Smith et al., 2004; Sutter-Dallay et al., 2004;
Uguz et al., 2010; Zar et al., 2002). One study reported on prevalence
rates for each trimester separately (Martini et al., 2013). Only one study
focused on the onset of PD during pregnancy and found that it usually
occurred in the 1st and 2nd trimesters (Guler et al., 2015). The same
study showed that women with a history of psychiatric illness, de-
pression or any anxiety disorder were at risk of pregnancy-onset PD.
Findings of the 6 studies of the course of PD during pregnancy
differed substantially. The proportion of women who experienced an
improvement of PD during pregnancy varied between 9% and 74%
(Bandelow et al., 2006; Klein et al., 1994), while the corresponding
proportion for the worsening of PD during pregnancy ranged from 5%
to 33% (Klein et al., 1994; Northcott and Stein, 1994). There were also
women whose PD did not seem to change in severity during pregnancy,
with such a course reported for 9%−84% of women with PD
(Villeponteaux et al., 1992; Bandelow et al., 2006).
The pooled data analysis revealed that the overall prevalence of PD
amongst pregnant females was 3% (95% CI: 2%−4%, p<0.001;
I2 = 78.73, p < 0.001). Pooled prevalence by trimester was reported as
3% (95% CI: 2%−5%, p < 0.001; I2 = 65.24, p = 0.09) in the first
trimester and 3% (95% CI: 2%−6%, p < 0.001; I2 = 79.22, p = 0.002)
in the third trimester. Egger's regression analysis found no evidence of
publication bias (p = 0.05).
29
Journal of Affective Disorders 255 (2019) 27–40
3.2. Obsessive-compulsive disorder
Table 2 summarises the characteristics and findings of the 14 studies
that examined the prevalence, onset and course of OCD during preg-
nancy. Prevalence rates of OCD during pregnancy were reported in 10
studies and ranged from 0.2% to 29.1% (Adewuya et al., 2006; Borri
et al., 2008; Chaudron and Nirodi, 2010; Farias et al., 2013; Giardinelli
et al., 2012; Sutter-Dalley et al., 2004; Uguz et al., 2007, 2010; Zar
et al., 2002). Prevalence rates were up to 5.2% across 8 studies, with
only one study (Chaudron and Nirodi, 2010) reporting a very high,
discrepant prevalence rate of 29.1%; this study was conducted in a
small sample of only 24 women. One study reported prevalence rates of
OCD in each trimester separately (Martini et al., 2013).
The onset of OCD during pregnancy was reported in a few studies,
with its frequency being 13.1% in one study (Williams and
Koran, 1997), 13.3% in another (Uguz et al., 2007) and 39.0% in a third
study (Neziroglu et al., 1992). The onset of OCD appeared to be more
common during the 2nd trimester of pregnancy (Kaya et al., 2015; Uguz
et al., 2007), closely followed by the onset in the 1st trimester
(Kaya et al., 2015).
Three studies (Uguz et al., 2011, 2007; Williams and Koran, 1997)
reported on the course of pre-existing OCD during pregnancy. The
proportion of women who experienced improvement in their pre-ex-
isting OCD symptoms ranged from 13.5% to 23.1%, whereas between
17% and 46.1% of women reported worsening of OCD symptoms
during pregnancy. The proportion of women who experienced no
change in OCD symptoms during pregnancy ranged from 30.8% to
69%.
The pooled data analysis revealed that the overall prevalence of
OCD amongst pregnant females was 3% (95% CI: 2%−5%, p < 0.001;
I2 = 87.71, p < 0.001). Pooled prevalence by trimester was reported as
3% (95% CI: 1%−13%, p < 0.001; I2 = 94.20, p < 0.001) in the first
trimester and 4% (95% CI: 3%−6%, p < 0.001; I2 = 17.78, p = 0.27)
in the third trimester. Egger's regression analysis found no evidence of
publication bias (p = 0.73).
3.3. Generalized anxiety disorder
The results of 9 studies that reported prevalence rates of GAD during
pregnancy are summarised in Table 3, with prevalence rates ranging
from 0.9% to 22.7% (Adewuya et al., 2006; Borri et al., 2008; Coelho
et al., 2011; Farais et al., 2013; Gardinelli et al., 2012; Sutter-Dalley
 Table 1
Panic disorder with or without agoraphobia–prevalence, onset and course during pregnancy.
Study & country Sample size Study design Measures Assessment Points During Pregnancy and Number of Findings and comments
Assessments
K. Viswasam, et al.

Guler et al. (2015) Turkey
20 pregnant women with PD
Cross-sectional SCID (DSM-IV) Semi-structured interview Any time during pregnancy Onset of PD during pregnancy:
developed for study
1 assessment 50.0% (n = 10) in 1st trimester
45.0% (n = 9) in 2nd trimester
5.0% (n = 1) in 3rd trimester

Marchesi et al. (2014) Italy 277 pregnant women Prospective PRIME-MD Monthly during pregnancy Prevalence of PD during pregnancy:
7.5% (n = 21)
HADS 1 assessment per month
Martini et al. (2013) Germany 1st trimester: Prospective CIDI-V 1st, 2nd and 3rd trimesters Prevalence of PD during 1st trimester:
2.3% (n = 7)
306 women DASS-P 3 assessments Prevalence of PD during 2nd trimester:
5.1% (n = 15)
2nd trimester: Prevalence of PD during 3rd trimester:
0.4% (n = 1)
293 women
3rd trimester:
278 women
Farais et al. (2013) Brazil 239 pregnant women Cross-sectional MINI 1st trimester Prevalence of PD during 1st trimester:
0.4% (n = 1)
1 assessment
Giardinelli et al. (2012) Italy 590 pregnant women Prospective STAI-Y 3rd trimester Prevalence of PD during pregnancy:
5.4% (n = 32)
SCID (DSM-IV) 1 assessment

30
Interview developed for study
Uguz et al. (2010) Turkey 309 pregnant women Cross-sectional SCID (DSM-IV) Any time during pregnancy Prevalence of PD during pregnancy:
1.9% (n = 6)
1 assessment
Guler et al. (2008) Turkey 512 pregnant women Cross-sectional SCID (DSM-IV) 3rd trimester Prevalence of PD during pregnancy:
2.5% (n = 13)
PAS 1 assessment

Borri et al. (2008) Italy 1066 pregnant women Cross-sectional SCID (DSM-IV) 1st trimester Prevalence of PD during pregnancy:
4.0% (n = 43)
Unspecified number of assessments
Rogal et al. (2007) USA 1079 pregnant women Prospective MINI Any time during pregnancy Prevalence of PD during pregnancy:
2.0% (n = 22)
PRIME-MED Unspecified number of assessments
BHQ
Bandelow et al. (2006) Germany 93 pregnant women with PD (195 Retrospective SCID (DSM-IV) Unspecified number of assessments Course of PD during pregnancy:
pregnancies)
Questionnaire developed for study 8.7% (n = 17) improved
Interview developed for study 84.6% (n = 165) no change
6.6% (n = 13) worsened
Adewuya et al. (2006) Nigeria 172 pregnant women Cross-sectional MINI 3rd trimester Prevalence of PD during pregnancy:
5.2% (n = 9)
1 assessment
Sutter-Daley et al. (2004) France 497 pregnant women Prospective MINI 3rd trimester Prevalence of PD during pregnancy:
1.4% (n = 7)
Socio-demographic questionnaire developed 1 assessment
for study
Smith et al. (2004) USA 387 pregnant women Cross-sectional MINI Any time during pregnancy Prevalence of PD during pregnancy:
2.3% (n = 9)
(continued on next page)
Journal of Affective Disorders 255 (2019) 27–40
 Table 1 (continued)

Study & country Sample size Study design Measures Assessment Points During Pregnancy and Number of Findings and comments
Assessments
K. Viswasam, et al.

PRIME-MED 1 assessment
BPHQ
Zar et al. (2002) Sweden 453 pregnant women Cross-sectional ASQ I 2nd and 3rd trimester Prevalence of PD during pregnancy:
1.3% (n = 6)
ADIS-R 2 assessments

Cohen et al. (1996) USA
Klein et al. (1994) USA
Cohen et al. (1994) USA
Northcott & Stein (1994) USA
10 pregnant women with PD
19 pregnant women with PD
49 pregnant women with PD
46 pregnant women with PD (67
pregnancies)
Prospective SCID (DSM-III-R) 1 assessment in each trimester Course of PD during pregnancy:
CGI 3 assessments 10.0% (n = 1) improved
60.0% (n = 6) no change
30.0% (n = 3) worsened
Retrospective Retrospective self-reports Unspecified whether or not assessments were Course of PD during pregnancy:
performed during pregnancy
Interview developed for study 1 assessment 73.6% (n = 14) improved
21.0% (n = 4) no change
5.2% (n = 1) worsened
Retrospective CGI Unspecified number of assessments Course of PD during pregnancy:
20.4% (n = 10) improved
57.1% (n = 28) no change
20.4% (n = 10) worsened
2.0% (n = 1) variable course
Retrospective Questionnaire developed for study Unspecified number of assessments Course of PD during pregnancy:
43.2% (n = 29) improved
23.8% (n = 16) no change
32.8% (n = 22) worsened

31
Villeponteaux et al. (1992) USA 22 pregnant women with PD Retrospective Questionnaire developed for study Unspecified number of assessments Course of PD during pregnancy:
63.6% (n = 14) improved
9.0% (n = 2) no change
13.6% (n = 3) worsened
13.6% (n = 3) variable course

ADIS-R = Anxiety Disorder Interview Schedule-Revised, ASQ I = Anxiety Symptoms Questionnaire Part I, BHQ = Brief Patient Health Questionnaire, CGI = Clinical Global Impressions Scale, CIDI-V = Composite
International Diagnostic Interview for Women, DASS-P = Depression-Anxiety-Stress Scale for Peripartum, HADS = Hospital Anxiety Depression Scale, MINI = Mini International Neuropsychiatric Interview,
PAS = Panic and Agoraphobia Scale, PRIME-MED = Primary Care Evaluation of Mental Disorders, SCID (DSM-III-R) = Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised, SCID (DSM-IV) = Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, STAI-Y = State-Trait Anxiety Inventory.
Journal of Affective Disorders 255 (2019) 27–40
 Table 2
Obsessive Compulsive Disorder (OCD)–prevalence, onset and course during pregnancy.
Study & country Sample size Study design Measures Assessment Points During Findings and comments
Pregnancy & Number of
K. Viswasam, et al.

Assessments

Kaya et al. (2015) Turkey 20 pregnant women who had an Cross-sectional SCID (DSM-IV) Any time during pregnancy Onset of OCD during pregnancy:
onset of OCD during pregnancy
Y-BOCS Unspecified number of 45.0% (n = 9) in the 1st trimester
assessments
50.0% (n = 10) in the 2nd trimester
5.0% (n = 1) in the 3rd trimester
Martini et al. (2013) Germany 1st trimester: Prospective CIDI-V 1st, 2nd and 3rd trimesters Prevalence of OCD during 1st trimester: 2.0%
(n = 6)
306 women DASS-P 3 assessments Prevalence of OCD during 2nd trimester: 0.0%
(n = 0)
2nd trimester: Prevalence of OCD during 3rd trimester: 0.4%
(n = 1)
293 women
3rd trimester:
278 women

Farais et al. (2013) Brazil 239 pregnant women Cross-sectional MINI 1st trimester Prevalence of OCD during 1st trimester: 3.4%
(n = 8)
1 assessment
Giardinelli et al. (2012) Italy 590 pregnant women Prospective STAI-Y 3rd trimester Prevalence of OCD during pregnancy: 3.3%
(n = 20)
SCID (DSM-IV) 1 assessment
Interview developed for study

32
Uguz et al. (2011) Turkey
Chaudron & Nirodi (2010) USA
Uguz et al. (2010)
Turkey
Borri et al. (2008) Italy
Uguz et al. (2007) Turkey
Adewuya et al. (2006) Nigeria
Sutter-Daley et al. (2004) France
52 pregnant women with OCD Retrospective SCID (DSM-IV) Unspecified number of Course of pre-existing OCD during pregnancy:
assessments
Y-BOCS 13.5% (n = 7) improved
Retrospective reports by patients for 53.8% (n = 28) no change
changes in OCD symptoms
32.7% (n = 17) worsened
24 pregnant women Longitudinal SCID (DSM-IV) 3rd trimester Prevalence of OCD during pregnancy: 29.1% (n = 7)
Y-BOCS 1 assessment
309 pregnant women Cross-sectional SCID (DSM-IV) Any time during pregnancy Unspecified number of assessments
Prevalence of OCD during pregnancy:
5.2% (n=16)
1066 pregnant women Cross-sectional SCID (DSM-IV) 1st trimester Prevalence of OCD during pregnancy: 1.6% (n = 17)
Unspecified number of
assessments
434 pregnant women Prospective SCID (DSM-IV) 3rd trimester Course of 13 pre-existing OCD during pregnancy:
(15 with OCD)
Y-BOCS Unspecified number of 23.1% (n = 3) improved
assessments
Semi-structured interview developed for 30.8% (n = 4) no change
study assessing the course of OCD during
pregnancy
46.1% (n = 6) worsened
Onset of OCD during pregnancy:
13.3% (n = 2) in the 2nd trimester
Prevalence of OCD during pregnancy: 3.5% (n = 15)
172 pregnant women Cross-sectional MINI 3rd trimester Prevalence of OCD during pregnancy: 5.2% (n = 9)
1 assessment
497 pregnant women Prospective MINI 3rd trimester Prevalence of OCD during pregnancy: 1.2% (n = 6)
(continued on next page)
Journal of Affective Disorders 255 (2019) 27–40
K. Viswasam, et al. Journal of Affective Disorders 255 (2019) 27–40

ADIS-R = Anxiety Disorder Interview Schedule-Revised, ASQ I = Anxiety Symptoms Questionnaire Part One, CIDI-V = Composite International Diagnostic Interview for Women, DASS-P = Depression-Anxiety-Stress
Scale for Peripartum, MINI = Mini-International Neuropsychiatric Interview, SCID (DSM-IV) = Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, STAI-Y = State-
et al., 2004; Uguz et al., 2010; Zar et al., 2002). One study reported

(13.1% of 38 women with OCD); trimester of

Course of pre-existing OCD during pregnancy

Onset of OCD during pregnancy in 5 women

prevalence rates of GAD in each trimester separately (Martini et al.,

Prevalence of OCD during pregnancy: 0.2%

2013). There were no studies that investigated the onset and course of

39.0% (n = 23), trimester of onset not

GAD during pregnancy.
The pooled data analysis revealed that the overall prevalence of

Onset of OCD during pregnancy:

GAD amongst pregnant females was 3% (95% CI: 2%−7%, p < 0.001;
I2 = 95.18, p < 0.001). Pooled prevalence by trimester was reported as

68.9% (n=20) no change

13.7% (n=4) improved

17.2% (n=5) worsened

Findings and comments

3% (95% CI: 1%−12%, p < 0.001; I2 = 95.88, p < 0.001) in the first

onset not specified

trimester, 3% (95% CI: 0%−74%, p = 0.133; I2 = 94.82, p = 0.001) in
the second trimester and 3% (95% CI: 1%−8%, p < 0.001; I2 = 93.51,
in 29 women:

p < 0.001) in the third trimester. Egger's regression analysis found

specified
evidence of publication bias (p = 0.006), with a fail-safe number of
(n = 1)

3392.

3.4. Specific phobia

Assessment Points During

Results and characteristics of 6 studies of the prevalence of specific

Pregnancy & Number of

Unspecified number of

Unspecified number of
2nd and 3rd trimester

phobia during pregnancy are presented in Table 4, with prevalence

rates ranging from 3.2% to 19.9% (Adewuya et al., 2006; Giardinelli
et al., 2012; Lilliecreutz et al., 2011; Uguz et al., 2010; Zar et al., 2002).
2 assessments
Assessments

assessments

assessments

In 4 out of 5 studies, prevalence rates were lower than 10%.

Zar et al. (2002) found that the prevalence of an extreme fear of giving
birth was 2.4% in their sample of 453 pregnant women. One study
reported prevalence rates of specific phobia in each trimester of preg-
1 assessment

Questionnaire developed for study

nancy separately (Martini et al., 2013). There were no studies of the

Standardized telephone interview

onset and course of specific phobia during pregnancy.

The pooled data analysis revealed that the overall prevalence of
developed for the study

specific phobia amongst pregnant females was 6% (95% CI: 4%−10%,

Socio-demographic questionnaire developed

p < 0.001; I2 = 94.79, p < 0.001). Pooled prevalence by trimester was

reported as 15% (95% CI: 11%−19%, p < 0.001; I2 = 0.00, p = 1.00)
in the first trimester, 9% (95% CI: 2%−38%, p = 0.013; I2 = 96.83,
Measures

p < 0.001) in the second trimester and 4% (95% CI: 2%−8%,

ADIS-R
ASQ I

p < 0.001; I2 = 87.45, p < 0.001) in the third trimester. Egger's re-
gression analysis found no evidence of publication bias (p = 0.10).

3.5. Social anxiety disorder

Nine studies examining prevalence of social anxiety disorder during

for study

pregnancy are summarised in Table 5. Prevalence rates reported for

social anxiety disorder during pregnancy varied between 2.0% and
27.6% (Adewuya et al., 2006; Borri et al., 2008; Coelho et al., 2011;
Farais et al., 2013; Giardinelli et al., 2012; Lilliecreutz et al., 2011;
Sutter-Daley et al., 2004; Uguz et al., 2010; Zar et al., 2002), with these
Cross-sectional

Trait Anxiety Inventory, Y-BOCS = Yale-Brown Obsessive-Compulsive Scale.

Retrospective

Retrospective
Study design

rates being lower than 7% in 7 out of 8 studies. One study reported

prevalence rates of social anxiety disorder in each trimester of preg-
nancy separately (Martini et al., 2013). There were no studies of the
onset and course of social anxiety disorder during pregnancy.
The pooled data analysis revealed that the overall prevalence of
59 women with OCD and previous
38 pregnant women with OCD

social anxiety disorder amongst pregnant females was 3% (95% CI:

2%−7%, p < 0.001; I2 = 95.44, p < 0.001). Pooled prevalence by tri-
mester was reported as 4% (95% CI: 3%−5%, p < 0.001; I2 = 12.29,
453 pregnant women

p = 0.32) in the first trimester, 6% (95% CI: 0%−69%, p = 0.131;

I2 = 97.25, p < 0.001) in the second trimester and 3% (95% CI:
pregnancies

1%−6%, p < 0.001; I2 = 77.06, p = 0.005) in the third trimester.

Sample size

Egger's regression analysis found evidence of publication bias

(p = 0.03), with a fail-safe number of 3671.

3.6. Posttraumatic stress disorder

Neziroglu et al. (1992) USA
Williams & Koran (1997)
Zar et al. (2002) Sweden

Table 6 summarises the results of 14 studies examining the pre-

Table 2 (continued)

valence and onset of PTSD during pregnancy. Prevalence rates of PTSD

Study & country

during pregnancy ranged from 0.6% to 16.0% (Adewuya et al., 2006;

Ayers and Pickering, 2001; Borri et al., 2008; Giardinelli et al., 2012;
Loveland Cook et al., 2004; Morland et al., 2007; Rogal et al., 2007;
USA

Seng et al., 2010; Smith et al., 2004, 2006; Soderquist et al., 2004; Zar
et al., 2002), with 11 out of 13 studies reporting prevalence rates lower

33
 K. Viswasam, et al.

Table 3
Generalized Anxiety Disorder (GAD)–prevalence, onset and course during pregnancy.
Study & country Sample Size Study Design Measures Assessment Points During Pregnancy & Number of Findings and Comments
Assessments

Martini et al. (2013) Germany 1st trimester: Prospective CIDI-V 1st, 2nd and 3rd trimesters Prevalence of GAD during 1st trimester: 1.3%
(n = 4)
306 women DASS-P 3 assessments Prevalence of GAD during 2nd trimester: 0.3%
(n = 1)
2nd trimester: Prevalence of GAD during 3rd trimester: 1.8%
(n = 5)
293 women
3rd trimester: 278
women
Farais et al. (2013) Brazil 239 pregnant women Cross-sectional MINI 1st trimester Prevalence of GAD during 1st trimester: 10.5%
(n = 25)
1 assessment
Giardinelli et al. (2012) Italy 590 pregnant women Prospective STAI-Y 3rd trimester Prevalence of GAD during pregnancy: 1.3%
(n = 8)
SCID (DSM-IV) 1 assessment
Interview developed for study
Coelho et al. (2011) UK 246 pregnant women Prospective SCID (DSM-IV) 2nd trimester (at 20 weeks) Prevalence of GAD during pregnancy: 22.7%

34
(n = 56)
1 assessment
Uguz et al. (2010) Turkey 309 pregnant women Cross-sectional SCID (DSM-IV) Any time during pregnancy Prevalence of GAD during pregnancy: 3.5%
(n = 11)
1 assessment
Borri et al. (2008) Italy 1066 pregnant women Cross-sectional SCID (DSM-IV) 1st trimester Prevalence of GAD during pregnancy: 1.9%
(n = 20)
Unspecified number of assessments
Adewuya et al. (2006) Nigeria 172 pregnant women Cross-sectional MINI 3rd trimester Prevalence of GAD during pregnancy: 10.5%
(n = 18)
1 assessment
Sutter-Dalley et al. (2004) France 497 pregnant women Prospective MINI 3rd trimester Prevalence of GAD during pregnancy: 10.3%
(n = 51)
Socio-demographic questionnaire developed for 1 assessment
study
Zar et al. (2002) Sweden 453 pregnant women Cross-sectional ASQ I 2nd and 3rd trimesters Prevalence of GAD during pregnancy: 0.9%
(n = 4)
ADIS-R 2 assessments

ADIS-R = Anxiety Disorder Interview Schedule-Revised, ASQ I = Anxiety Symptoms Questionnaire Part One, CIDI-V = Composite International Diagnostic Interview for Women, DASS-P = Depression-Anxiety-Stress
Scale for Peripartum, MINI = Mini International Neuropsychiatric Interview, SCID (DSM-IV) = Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, STAI-Y = State-
Trait Anxiety Inventory.
Journal of Affective Disorders 255 (2019) 27–40
 K. Viswasam, et al.

Table 4
Specific phobia–prevalence, onset and course during pregnancy.
Study & country Sample size Study design Measures Assessment Points During Pregnancy & Number of Findings and comments
Assessments

Martini et al. (2013) Germany - 1st trimester: Prospective CIDI-V 1st, 2nd and 3rd trimesters Prevalence of specific phobia during 1st trimester: 14.7%
(n = 45)
306 women DASS-P 3 assessments Prevalence of specific phobia during 2nd trimester: 3.8%
(n = 11)
- 2nd trimester: Prevalence of specific phobia during 3rd trimester: 2.5%
(n = 7)
293 women
- 3rd trimester: 278 women
Giardinelli et al. (2012) Italy 590 pregnant women Prospective STAI-Y 3rd trimester Prevalence of specific phobia during pregnancy: 3.5% (n = 21)
SCID (DSM-IV) 1 assessment
Interview developed for

35
study
Lilliecreutz et al. (2011) Sweden 1529 pregnant women Prospective IPSA 1st and 2nd trimesters Prevalence of specific phobia during pregnancy: 7.1%
(n = 110)
BAI 2 assessments
Uguz et al. (2010) Turkey 309 pregnant women Cross-sectional SCID (DSM-IV) Any time during pregnancy Prevalence of specific phobia during pregnancy: 3.2% (n = 10)
1 assessment
Adewuya et al. (2006) Nigeria 172 pregnant women Cross-sectional MINI 3rd trimester Prevalence of specific phobia during pregnancy: 9.3% (n = 16)
1 assessment
Zar et al. (2002) Sweden 453 pregnant women Cross-sectional ASQ I 2nd and 3rd trimesters Prevalence of specific phobia during pregnancy: 19.9%
(n = 90)
ADIS-R 2 assessments Prevalence of extreme fear of birth during pregnancy: 2.4%
(n = 11)
W-DEQ

ADIS-R = Anxiety Disorder Interview Schedule-Revised, ASQ I = Anxiety Symptoms Questionnaire Part I, BAI = Beck Anxiety Inventory, CIDI-V = Composite International Diagnostic Interview for Women, DASS-
P = Depression-Anxiety-Stress Scale for Peripartum, IPSA = Injection Phobia Scale-Anxiety, MINI = Mini International Neuropsychiatric Interview, SCID (DSM-IV) = Structured Clinical Interview for the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, STAI-Y = State-Trait Anxiety Inventory, W-DEQ = Wijma Delivery Expectancy/Experience Questionnaire.
Journal of Affective Disorders 255 (2019) 27–40
K. Viswasam, et al.
than 8%. One study reported prevalence rates of PTSD in each trimester
of pregnancy separately (Martini et al., 2013). There were no studies of
the onset and course of PTSD during pregnancy.
The pooled data analysis revealed that the overall prevalence of
PTSD amongst pregnant females was 3% (95% CI: 2%−4%, p < 0.001;
I2 = 92.03, p < 0.001). Pooled prevalence by trimester was reported as
3% (95% CI: 0%−12%, p < 0.001; I2 = 95.04, p < 0.001) in the first
trimester, 0% (95% CI: 0%−3%, p < 0.001; I2 = 0.00, p = 1.00) in the
second trimester and 1% (95% CI: 0%−7%, p < 0.001; I2 = 90.49,
p < 0.001) in the third trimester. Egger's regression analysis found
evidence of publication bias (p = 0.004), with the fail-safe number of
56.
4. Discussion
To the best of our knowledge, this is the first combined systematic
review and meta-analysis of the prevalence, onset and course of anxiety
disorders during pregnancy. The inclusion of a meta-analysis was im-
portant because it complemented findings of the systematic review by
providing greater quantitative precision. Each of the previous three
systematic reviews (Goodman et al., 2014; Leach et al., 2015; Ross and
McLean 2006) was conducted without a meta-analysis. In addition,
these systematic reviews focused mainly on the prevalence and course
of anxiety disorders during pregnancy and/or postpartum, and only one
of them (Ross and McLean, 2006) also addressed the onset of anxiety
disorders during this period. However, that study did not investigate all
anxiety disorders. Unlike previous research, the present study was both
pregnancy-focused (in that it excluded findings pertaining to the post-
partum period) and comprehensive (in that it encompassed all anxiety
disorders plus OCD and PTSD). These considerations highlight a need
for our systematic review and meta-analysis. The strengths of the pre-
sent study whose main findings are summarised in Table 7 also include
a comprehensive literature search strategy using multiple databases and
strict inclusion criteria to reduce the possibility of bias.
4.1. Prevalence of anxiety disorders
Our study confirms that anxiety disorders are common during
pregnancy and that prevalence rates of the specific anxiety disorders
during pregnancy vary considerably between various studies (Table 7).
Importantly, compared to their lifetime prevalence rates in women in
the general population, PD and OCD were found to be more common
during pregnancy. Thus, the PD and OCD prevalence rates of 3% each
during pregnancy were higher than the lifetime PD and OCD prevalence
rates in women in the general population, which were both 1.6%
(Somers et al., 2006). In contrast, the prevalence rates of GAD, specific
phobia and PTSD during pregnancy were lower than the lifetime pre-
valence rates of these disorders in women in the general population: 3%
for GAD during pregnancy versus 8.4% for GAD in women in the gen-
eral population (Somers et al., 2006), 6% for specific phobia during
pregnancy versus 8.2% for specific phobia in women in the general
population (Somers et al., 2006) and 3% for PTSD during pregnancy
versus 10.4% for PTSD in women in the general population (Kessler
et al., 1995). The prevalence rate of social anxiety disorder during
pregnancy (3%) was similar to that of social anxiety disorder in women
in the general population (2.9%; Somers et al., 2006).
Although studies do not provide sufficient data to make adequate
comparisons of the proportions of women with pre-existing anxiety
disorders with the proportions of women with a new onset of anxiety
disorders during pregnancy, these findings suggest that pregnancy may
be a specific risk factor for the occurrence and/or exacerbation of PD
and OCD. A possible reason for the occurrence of PD during pregnancy
could be traced back to sudden changes in bodily sensations during
pregnancy, such as increased heart and respiratory rates, chest tightness
and shortness of breath (Guler et al., 2015; Smith et al., 2004). If the
woman is particularly sensitive to such changes, perhaps as a result of
36
Journal of Affective Disorders 255 (2019) 27–40
heightened anxiety sensitivity, they can be instrumental in precipitating
panic attacks. Elevated levels of progesterone, oestradiol and cortisol
during pregnancy have also been implicated in the aetiology of panic
attacks (Bandelow et al., 2006). With regards to OCD, fluctuations in
gonadal steroid levels during pregnancy may affect serotonin func-
tioning and thus facilitate the onset of OCD during pregnancy or its
exacerbation (Abramowitz et al., 2003; Labad et al., 2005). In addition,
there are psychological vulnerabilities specific for pregnancy, which
include body and health-centred concerns (relevant for PD), as well as
concerns about and responsibility for the foetus (relevant for OCD).
4.2. Onset of anxiety disorders
A few studies investigated the onset of anxiety disorders during
pregnancy and reported only on the onset of PD and OCD. While the
frequency of onset of PD during pregnancy is unclear, the onset of OCD
during pregnancy is not rare, with 13%−39% of all cases of OCD
having such an onset (Table 7). Further studies are needed to under-
stand the factors associated with the onset of OCD during pregnancy.
With regards to the timing of the onset of PD and OCD during preg-
nancy, the onset of PD usually occurred in the 1st and 2nd trimesters,
while the onset of OCD occurred mainly in the 2nd trimester, followed
closely by the onset in the 1st trimester. Understanding whether and
why any particular stage of pregnancy carries a greater risk of onset of
PD and OCD also calls for further research.
4.3. Course of anxiety disorders
Data on the course of anxiety disorders during pregnancy are also
limited to PD and OCD. Our findings show a large variability between
studies in terms of the frequencies of the three main trajectories of PD
and OCD during pregnancy: improvement, no change (stable course)
and worsening (Table 7). This variability precludes any conclusion
about the “typical” course of PD and OCD during pregnancy, and fac-
tors that determine whether symptoms of these and other anxiety dis-
orders become more or less prominent during pregnancy or do not
change in intensity are yet to be ascertained.
4.4. Limitations
This study had limitations such as the inclusion of articles published
only in English. Findings of every review and meta-analysis are con-
strained by the number and quality of the included studies, and the
present study is no exception. Thus, there were only a few studies in-
vestigating the onset and course of anxiety disorders during pregnancy.
The design of some studies was retrospective, with the attendant risk of
recall bias. Additionally, it was difficult to obtain definitive results
about pooled prevalence rates due to different measures used, study
designs and assessment times. With regards to assessment times, some
studies reported prevalence rates at a particular trimester, while others
did so at “any time during pregnancy”, thereby limiting our ability to
merge data from the available studies and provide definitive findings.
Similarly, the reported heterogeneity was most likely due to variations
between studies in the assessment of the specific disorders.
Studies included in this systematic review and meta-analysis did not
provide data on the factors that could influence the prevalence, onset
and course of anxiety disorders during pregnancy. These include levels
of stress and social support, occurrence of any traumatic events, ma-
ternal age and parity.
We found publication bias for studies of some anxiety disorders
(GAD, social anxiety disorder and PTSD). Still, the fail-safe method
showed that the number of studies would need to be high (>50 studies)
for our estimated prevalence rates to be affected. Considering that there
have been no more than 30 studies published over the past 20 years, it
is highly improbable that such a large number of similar studies would
have been unpublished or missed by our extensive search strategy.
 K. Viswasam, et al.

Table 5
Social anxiety disorder - prevalence, onset and course during pregnancy.
Study & country Sample size Study design Measures Assessment Points During Pregnancy & Number of Findings and comments
Assessments
Martini et al. (2013) Germany 1st trimester: Prospective CIDI-V 1st, 2nd and 3rd trimesters Prevalence of social anxiety disorder during 1st trimester:
2.3% (n = 7)
306 women DASS-P 3 assessments Prevalence of social anxiety disorder during 2nd trimester:
1.0% (n = 3)
2nd trimester: Prevalence of social anxiety disorder during 3rd trimester:
0.4% (n = 1)
293 women
3rd trimester:
278 women
Farais et al. (2013) Brazil 239 pregnant women Cross-sectional MINI 1st trimester Prevalence of social anxiety disorder during 1st trimester:
4.6% (n = 11)
1 assessment
Giardinelli et al. (2012) Italy 590 pregnant women Prospective STAI-Y 3rd trimester Prevalence of social anxiety disorder during pregnancy: 4.1%
(n = 24)
SCID (DSM-IV) 1 assessment
Interview developed for study
Coelho et al. (2011) UK 246 pregnant women Prospective SCID (DSM-IV) 2nd trimester (at 20 weeks) Prevalence of social anxiety disorder during

37
pregnancy:27.6% (n = 68)
1 assessment
Uguz et al. (2010) Turkey 309 pregnant women Cross-sectional SCID (DSM-IV) Any time during pregnancy Prevalence of social anxiety disorder during pregnancy: 3.2%
(n = 10)
1 assessment
Borri et al. (2008) Italy 1066 pregnant Cross-sectional SCID (DSM-IV) 1st trimester Prevalence of social anxiety disorder during pregnancy: 3.8%
women (n = 41)
Unspecified number of assessments
Adewuya et al. (2006) Nigeria 172 pregnant women Cross-sectional MINI 3rd trimester Prevalence of social anxiety disorder during pregnancy: 6.4%
(n = 11)
1 assessment
Sutter-Daley et al. (2004) France 497 pregnant women Prospective MINI 3rd trimester Prevalence of social anxiety disorder during pregnancy: 2.0%
(n = 10)
Socio-demographic questionnaire developed 1 assessment
for study
Zar et al. (2002) 453 pregnant women Cross-sectional ASQ I 2nd and 3rd trimester Prevalence of social anxiety disorder during pregnancy:
Sweden ADIS-R 2 assessments 2.7% (n=12)
W-DEQ

ADIS-R = Anxiety Disorder Interview Schedule-Revised, ASQ I = Anxiety Symptoms Questionnaire Part I, CIDI-V = Composite International Diagnostic Interview for Women, DASS-P = Depression-Anxiety-Stress Scale
for Peripartum, MINI = Mini International Neuropsychiatric Interview, SCID (DSM-IV) = Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, STAI-Y = State-Trait
Anxiety Inventory, W-DEQ = Wijma Delivery Expectancy/Experience Questionnaire.
Journal of Affective Disorders 255 (2019) 27–40
 Table 6
K. Viswasam, et al.

Post-Traumatic Stress Disorder (PTSD)–prevalence, onset and course during pregnancy.

Study & country Sample size Study design Measures Assessment Points During Pregnancy & Number of Assessments Findings and comments

Martini et al. (2013) Germany 1st trimester: Prospective CIDI-V 1st, 2nd and 3rd trimesters Prevalence of PTSD during 1st trimester: 2.0% (n = 6)
306 women DASS-P 3 assessments Prevalence of PTSD during 2nd trimester: 0.0% (n = 0)
2nd trimester: Prevalence of PTSD during 2nd trimester: 0.4% (n = 1)
293 women
3rd trimester:
278 women
Farais et al. (2013) Brazil 239 pregnant women Cross-sectional MINI 1st trimester Prevalence of PTSD during 1st trimester:1.7% (n = 4)
1 assessment
Giardinelli et al. (2012) Italy 590 pregnant women Prospective STAI-Y (10 item) 3rd trimester Prevalence of PTSD during pregnancy: 0.8% (n = 5)
SCID (DSM-IV)
Interview developed for study 1 assessment
Seng et al. (2010) USA 1581 pregnant women Cross-sectional NWS PTSD Module Prior to 28 weeks gestation Prevalence of PTSD during pregnancy: 7.9% (n = 125)
Standardised telephone interview 1 assessment
LSC-R
Borri et al. (2008) Italy 1066 pregnant women Prospective SCID (DSM-IV) 1st trimester Prevalence of PTSD during pregnancy: 0.7% (n = 7)
Unspecified number of assessments
Morland et al. (2007) USA 101 pregnant women Cross-sectional TLEQ 1st trimester Prevalence of PTSD during pregnancy: 16.0% (n = 16)
PCL-C Unspecified number of assessments
STAI (20 item)
CES-D
Rogal et al. (2007) USA 1100 pregnant women Prospective MINI Any time during pregnancy Prevalence of PTSD during pregnancy: 3.0% (n = 31)

38
Adewuya et al. (2006) Nigeria
Smith et al. (2006) USA
Loveland Cook et al. (2004) USA
Soderquist et al. (2004) Sweden
Smith et al. (2004) USA
Zar et al. (2002) Sweden
Ayers et al. (2001) UK
Unspecified number of assessments
172 pregnant women Cross-sectional MINI 3rd trimester Prevalence of PTSD during pregnancy: 0.6% (n = 1)
1 assessment
948 pregnant women Cross-sectional MINI (PTSD module) Any time during pregnancy Prevalence of PTSD during pregnancy: 3.5% (n = 33)
PRIME-MD Unspecified number of assessments
CIDI-V
744 pregnant women Prospective Diagnostic Interview Schedule Any time during pregnancy Prevalence of PTSD during pregnancy: 7.7% (n = 57)
Unspecified number of assessments
1224 pregnant women Prospective STAI-Y (20 item) 1st and 3rd trimesters Prevalence of PTSD during pregnancy: 2.3% (n = 28)
BDI 2 assessments
TLEQ
387 pregnant women Cross-sectional MINI (PTSD module) Any time during pregnancy Prevalence of PTSD during pregnancy: 2.6% (n = 10)
PRIME-MD 1 assessment
BHQ
453 pregnant women Cross-sectional ASQ I 2nd and 3rd trimester Prevalence of PTSD during pregnancy: 1.3% (n = 6)
ADIS-R 2 assessments
W-DEQ
222 pregnant women Prospective MMPI-2 PTSD Scale 3rd trimester Prevalence of PTSD during pregnancy:
GHQ-28 1 assessment 8.1% (n = 18) in 3rd trimester

ADIS-R = Anxiety Disorder Interview Schedule-Revised, ASQ I = Anxiety Symptoms Questionnaire Part One, BDI = Beck Depression Inventory, BHQ = Brief Patient Health Questionnaire, CES-D = Center for
Epidemiologic Studies Depression Scale, CIDI-V = Composite International Diagnostic Interview for Women, DASS-P = Depression Anxiety Stress Scale for Peripartum, GHQ-28 = 28 item General Health Questionnaires,
LSC-R = Life Stressor Checklist, MINI = Mini International Neuropsychiatric Interview,MMPI-2 PTSD Scale = Minnesota Multiphasic Personality Inventory – Post Traumatic Stress Disorder Scale, NWS PTSD
Module = PTSD Module from the National Women's Study, PRIME-MD = Primary Care Evaluation of Mental Disorders, PCL-C = PTSD Checklist–Civilian Version, SCID (DSM-IV) = Structured Clinical Interview for the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, STAIS = State-Trait Anxiety Inventory, TLEQ = Traumatic Life Events Questionnaire, W-DEQ = Wijma Delivery Expectancy/Experience
Questionnaire.
Journal of Affective Disorders 255 (2019) 27–40
K. Viswasam, et al. Journal of Affective Disorders 255 (2019) 27–40

5. Conclusion

17%−46.1%
Worsening

5%−33%
The aforementioned limitations notwithstanding, we conclude that
anxiety disorders are common during pregnancy, with the prevalence of

–
–

–
PD and OCD during pregnancy being higher than the lifetime pre-
30.8%−69%
valence of these disorders in women in the general population.
No change

9%−84%

Although data on the onset and course of anxiety disorders during

Course during pregnancy

pregnancy are sparse, it appears that the onset of OCD during preg-
–
–

–
nancy is not rare and that the course of PD and OCD during pregnancy
is highly variable. These findings have important clinical implications,
13.5%−23.1%
Improvement

including a need for prevention, early diagnosis and treatment, because

9%−74%

anxiety disorders during pregnancy have been associated with various

adverse outcomes. Future research should avoid methodological pitfalls
–
–

–
that has characterised studies conducted to date, with the aim of as-
• More common during the 2nd trimester, closely followed by onset in

certaining the potential role of pregnancy and other factors in pre-

• Usually occurred in the 1st and 2nd trimesters (based on 1 study)

cipitating the onset of various anxiety disorders during pregnancy and

influencing their course during this period.

Conflict of interest

All authors have no conflicts of interest to disclose.

• Frequency: 13%−39% (based on 3 studies)

Supplementary materials
the 1st trimester (based on 2 studies)

Supplementary material associated with this article can be found, in

the online version, at doi:10.1016/j.jad.2019.05.016.
Onset during pregnancy

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