{"paper_id":"5b222279-6458-45d2-b141-6aacbe3a24b9","body_text":"Emotion regulation is robustly associated with depressive symptoms across the \nperipartum – data from a prospective Swedish national cohort study \n \nFranziska Weinmar 1,2*, Emma Fransson 2,3, Birgit Derntl 1,4, and Alkistis Skalkidou 2* \n \n1 Department of Psychiatry and Psychotherapy, Women’s Mental Health and Brain Function, \nTübingen Center for Mental Health (TüCMH), University of Tübingen, Tübingen, Germany.  \n2 Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden. \n3 Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institute, Solna, \nSweden. \n4 Deutsches Zentrum für Psychische Gesundheit (DZPG), partner site Tübingen, Germany. \n \n* Correspondence should be addressed to:  \nDepartment of Psychiatry and Psychotherapy, Women’s Mental Health and Brain Function, \nUniversity of Tübingen, Calwerstrasse 14, 72076 Tübingen, Germany (FW). \nDepartment of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden, Dag \nHammarskjölds väg 14B, 75237 Uppsala (AS). \nE-mail addresses: Franziska.Weinmar@med.uni-tuebingen.de (FW), \nAlkistis.Skalkidou@uu.se (AS). \n \nORCID:  \nFW: https://orcid.org/0000-0002-0222-9402 \nEF: https://orcid.org/0000-0001-9010-8522  \nBD: https://orcid.org/0000-0003-0133-4486 \nAS: https://orcid.org/0000-0002-4935-7532 \n  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 2 \nKeypoints \n \n• Question. Are self-reported difficulties in emotion regulation (ER) in the second \ntrimester of pregnancy associated with depressive symptoms at multiple peripartum \ntimepoints?  \n \n• Findings. In this population-based prospective Swedish national cohort study, \ndifficulties in ER assessed in the second trimester were significantly associated with \nhigher depressive symptoms during pregnancy and up to six months postpartum, \neven after adjusting for potential confounders.   \n \n• Meaning. The study’s findings suggest that ER difficulties during pregnancy present a \nrobust vulnerability marker for depressive symptoms across the peripartum, \nespecially postpartum, and may provide an opportunity for early detection and \nintervention approaches of peripartum depression.   \n \n  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 3 \nAbstract \nImportance. Peripartum depression (PeriPD) is a prevalent condition with serious, long-term \nconsequences for mother and child. Emotion regulation (ER) is increasingly recognized as key \nfactor for maternal mental health and parenting. However, evidence remains limited regarding \nthe relation of ER difficulties and depressive symptoms across the peripartum. \nObjective. To determine whether self-reported ER difficulties in the antepartum are associated \nwith depressive symptoms at multiple peripartum timepoints. Secondary: Whether PeriPD \ntrajectories differ on antepartum ER difficulties.   \nDesign, Setting and Participants. Data for this study were collected from January 2022 to \nApril 2024 through the Mom2B cohort, a population-based, prospective Swedish national study \nusing a smartphone app for data collection. The cohort includes Swedish-speaking, pregnant \nwomen over 18 years, residing in Sweden, who downloaded the Mom2B app. Eligibility for this \nsub-study required verification of pregnancy and delivery, along with complete background \ninformation (N = 1414). Participants were included if they completed the Difficulties in Emotion \nRegulation Scale-16 (DERS-16) during the second trimester (N = 623). \nExposure. DERS-16 total score at 16-25 weeks antepartum.  \nOutcomes and Measures.  Depressive symptoms were assessed using the Edinburgh \nPostnatal Depression Scale (EPDS) at seven timepoints: 24-34, 36-42 weeks antepartum, and \n1-4, 6-13, 14-23, 24-35, 36-42 weeks postpartum. Multiple linear regression models examined \nDERS-16 scores as e xposure, with EPDS scores as outcomes, adjusting for potential \nconfounders. Secondary: Comparison of DERS-16 scores between PeriPD trajectories using \nANOVA.  \nResults. 623 pregnant women, aged 19 -44, were included. DERS -16 scores were strongly \nassociated with EPDS scores up to 14-23 weeks postpartum, even after adjusting for potential \nconfounders (all regression coefficients = .06 - .23, all 95% CIs = .00 - .26, all p-values < .05). \nSecondary: 134 participants were classified into a specific PeriPD trajectory. DERS-16 scores \ndiffered between trajectories (F(4,129) = 26.68, p < .001, ηp2  = .45), with higher ER difficulties \nin early and late postpartum-onset trajectories compared to the healthy group ( p = .017 and  \np = .018, respectively). \nConclusion and Relevance.  ER difficulties in the second trimester present a robust \nvulnerability marker for PeriPD symptoms, particularly for progression to postpartum \ndepression. The DERS-16 may aid in early detection of peripartum mental health risks, while \nenhancing ER offers a  promising intervention approach. Further research is needed to \nevaluate DERS -16’s clinical utility and optimize ER -centered interventions for at -risk \ntrajectories. \n \n \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 4 \nIntroduction \nPeripartum depression (PeriPD), including depressive episodes during pregnancy \n(antepartum depression, AntePD) or postpartum (postpartum depression, PostPD), is a \nprevalent mental health condition with serious, long -term consequences for both mother and \nchild.1-4 Despite affecting 7-17% of pregnant women and 10-20% of women after childbirth, up \nto four out of five affected women remain undiagnosed and untreated. 5,6 Research has \nidentified distinct PeriPD trajectories, such as antepartum -only depression resolving after \nchildbirth, depression with onset in the early or late postpartum period, or persistent symptoms \nacross the peripartum. 7-9 Although current clinical diagnostic criteria do not yet differentiate \nPeriPD trajectories10, they have been linked to different risk factors and may reflect distinct \nunderlying causes, suggesting the need for tailored diagnostics and interventions.9,11  \nEmotion regulation (ER), a transdiagnostic factor in mental health, is the ability to \nmonitor, understand, and modulate emotional experiences beyond merely suppressing \nemotions.12-14 ER is increasingly recognized as crucial for maternal mental health during the \nperipartum15-18, where maladaptive ER is associated with increased chronic stress 19, sleep \ndisturbances20, substance use21, and increased rates of depression, anxiety, and self-injurious \nthoughts.18,20-24 Furthermore, ER may impact parental health, c aregiving, and child \ndevelopment.18,22 In shaping the parent -child relationship, parental ER capacity is especially \nimportant for childhood behavioral development. 25 To assess ER, studies commonly use the \nDifficulties in Emotion Regulation Scale (DERS13), a validated self-report measure for clinical \nand non -clinical populations. 13,23,26,27 The DERS assesses key ER facets: emotional \nawareness, acceptance, impulse control, goal -directed behavior during negative emotions, \nand access to effective strategies.13,28 It shows strong internal consistency, construct validity, \nand clinical utility, particularly in peripartum samples, where it correlates well with anxiety and \ndepression measures.26 The 16-item short form, DERS -1629, retains excellent psychometric \nproperties, offering a brief yet reliable alternative for pregnant samples in time -constrained \nsettings.27,29 \nAs a modifiable ability, ER is critical for assessing mental health risks and serves as a \npotential intervention target during the peripartum. 30 However, research on how  ER during \npregnancy relates to depressive symptoms and PeriPD trajectories is limited. Addressing this \ngap, the current study investigated ER using the DERS -16 during the second trimester of \npregnancy and their association with depressive symptoms at multiple peripartum timepoints, \nusing data from a population-based, prospective Swedish national cohort study. Additionally, \nwe analyzed ER differences across PeriPD subgroups based on onset and persistence of \nsymptoms. This study ulti mately aims to assess the utility of the DERS -16 as a concise \nscreening tool during pregnancy, supporting PeriPD risk assessment and guiding prevention \nand intervention strategies. 26,28,29,31 We hypothesized ER difficulties reported in the second \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 5 \ntrimester to be associated with elevated depressive symptoms across the peripartum23,24,26,27, \nand given that distinct PeriPD trajectories are associated with diverse background factors9, we \nexpected ER capacity to vary between PeriPD trajectories. \n \nMethods \nParticipants and procedure \nData were obtained from the Mom2B cohort (www.mom2b.se), an ongoing, prospective \nSwedish national study using a smartphone -app for data collection. 32 All Swedish-speaking \nwomen over 18 residing in Sweden, who are pregnant or within three months postpartum, can \nparticipate by downloading the Mom2B app. Recruitment occurs via healthcare facilities, social \nmedia, and print advertisements. After providing informed consent, participants complete \nonline surveys accessible at designated peripartum periods. 32 Pregnancy and delivery are \nconfirmed via the Swedish national birth registry. The study complies with General Data \nProtection Regulations and has ethical approval from the Swedish Ethical Review Committee \n(dnr: 2019/01170, with amendments). Compared to Sweden’s general pregnant population, \nthe Mom2B cohort has a higher proportion of highly educated individuals and a lower \nproportion of participants born outside Sweden. 32-34 This study used data collected between \n01/2022 to 04/2024, specifically including responses to the DERS -1629 which was included \nfrom 05/2022 on and was available for participants at 16 -25 weeks antepartum. Eligibility \ncriteria included verified pregnancy and delivery, complete background information (N = 1414), \nand a completed DERS-16 during the specified period (N = 623). The Mom2B app allows users \nto join at any pregnancy stage, but survey access is limited to specific time windows, which \ncan result in missing data–a common issue in mobile health research35 \nSociodemographic information \nIn the background questionnaire participants reported in the app country of birth, age \nat registration, highest education level (“no schooling”, “primary school”, “high school”, \n“polytechnic/vocational training”, “university or college”), mental health history (“no”, “yes, with \nprofessional help”, “yes, without professional help”), and parity. Additional information included \nheight and weight (body -mass-index ( BMI) calculation ), relationships status (“no partner”, \n“partner, cohabiting”, “with a partner, no cohabiting”), partner violence history, substance use \nthree months before pregnancy (alcohol, cigarettes, snus), mental health issues due to oral \ncontraceptives (OC), past treatment for premenstrual disorders, and pregnancy loss history \n(all “yes”/“no”). After birth, participants reported mode of delivery (“vaginal delivery”, “assisted \nvacuum delivery”, “planned caesarean section”, “emergency caesarean section”) and neonatal \nissues up to 2 weeks postpartum (“yes”/”no”). Breastfeeding was tracked up to 42 we eks \npostpartum (“yes, full/partly”, “no”).   \n \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 6 \nDifficulties in Emotion Regulation Scale-16 \nEmotion regulation was measured with the Difficulties in Emotion Regulation Scale-16 \n(DERS-1629), a 16-item short form of the DERS 13, at 16 -25 weeks antepartum and 17 -25 \nweeks postpartum. The DERS -16 assesses trait -level emotion dysregulation using five \nsubscales: : (1) Lack of emotional clarity, e.g., “I have difficulty making sense out of my \nfeelings”; (2) Non-acceptance of emotional responses, e.g., “When I’m upset, I become angry \nat myself fore feeling that way”; (3) Impulse control difficulties, e.g., “When I’m upset, I become \nout of control”; (4) Difficulty in engaging in goal-directed behavior, e.g., “When I’m upset, I have \ndifficulty getting work done”; (5) Limited access to emotion regulation strategies, e.g., “When \nI’m upset, I believe there is nothing I can do to feel better” .27-29 Scores range from 16 to 80, \nwith higher scores indicating greater emotion dysregulation. 13,29 The DERS -16 has shown \nstrong psychometric properties, including high internal consistency, test -retest reliability, and \nconvergent and discriminant validity29, also in peripartum samples.26 \nEdinburgh Postnatal Depression Scale \nPeriPD symptoms were measured using the Swedish version of the Edinburgh \nPostnatal Depression Scale (EPDS 36-38) at eight timepoints: 12 -22, 24-34, and 36-42 weeks \nantepartum as well as 1-4, 6-13, 14-23, 24-35, and 36-42 weeks postpartum. The EPDS is a \nvalidated 10-item self -report screening tool assessing depressive symptoms over the past \nseven days, with higher scores indicating greater severity.37,38 Scores of ≥13 antepartum and \n≥12 postpartum indicate clinically relevant symptoms, as validated in Swedish samples. 37,38 \nThese cut -off scores were also used for the pres ent secondary analyses in the PeriPD \ntrajectories9. If respondents completed nine of ten items, the missing score was imputed with \nthe mean of the other items; with fewer than nine completed items, the total score was set to \nmissing.  \nAdditional psychometric surveys \nBased on a study using data from a population -based prospective cohort study and \nmachine learning methods to predict depressive symptoms six weeks postpartum 39 we \nincluded additional psychometric scales provided via the Mom2B app  during antepartum as \npotential confounders for our primary analyses. The extra surveys included the Fear of Birth \nScale (FOBS40), Resilience Scale-14 (RS-1441,42), Sense of Coherence Scale-13 (SOC-1343,44), \nand the Vulnerable Personality Style Questionnaire (VPSQ 45,46). Delivery experience was \nassessed via a visual analogue scale with low values indicating a negative and high values \nindicating a positive delivery experience.  \nStatistical analyses \nFor all statistical analyses, IBM SPSS Statistics (version 28.0) was used and the alpha \ncriterion level set to p ≤ .05. \n \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 7 \nEmotion regulation across the peripartum \nTo assess emotion regulation across peripartum, we performed a Pearson correlation \nanalysis of DERS -16 total score at 16 -25 weeks antepartum with scores at 17 -25 weeks \npostpartum. A paired samples t -test was conducted to test if DERS -16 total score s were  \ndifferent in the postpartum compared to the antepartum assessment period. \nPrimary analyses: Association of ER and peripartum depressive symptoms  \nTo assess the association of ER and depressive symptoms, we performed multiple \nlinear regression models with the DERS -16 total score at 16 -25 weeks antepartum as the \nexposure and EPDS total score across peripartum ( 24-34, 36-42 weeks antepartum; 1 -4, 6-\n23, 24-35, 36-42 weeks postpartum), as outcomes, respectively. Model 1 was unadjusted for \nany other potential confounders; Model 2 adjusted for potential confounders including age, \npre-pregnancy BMI, university-level of education, parity, pregnancy loss history, self-reported \nhistory of depression, treatment for premenstrual disorder, mental health issues from OC use, \nmean FOBS, RS -14, SOC -13, and VPSQ scores (all assessed antepartum). Postpartum \nEPDS outcomes were additionally adjusted for delivery experience , neonatal issues (0 -2 \nweeks postpartum) and in Model 3 also adjusted for EPDS score at 12-22 weeks antepartum.  \nSecondary analyses: ER across PeriPD trajectories \nTo explore ER differences across PeriPD trajectories, we categorized participants into \nfive groups based on EPDS scores above the clinical cut -offs (≥13 antepartum, ≥12 \npostpartum) following Wikman et al. 9: (1) healthy (no depressive symptoms antepartum or \npostpartum), (2) antepartum-only depression, (3) early postpartum-onset depression, (4) late \npostpartum-onset depression, and (5) persistent depression. Group differences between \nEPDS responders and non -responders (those completing DERS -16 but missing any  EPDS \nassessment) were tested using t-tests or Chi-squared tests. Trajectory group differences were \nanalyzed with Fisher’s Exact test for categorical variables, ANOVA, or Kruskal-Wallis H tests, \nif homogeneity of variance was violated. To assess DERS -16 score differences by PeriPD \ntrajectory, univariate ANOVA was used, with effect sizes reported as ηp2 and Bonferroni -\nadjusted post-hoc tests for significant effects. \n \nResults \nSample characteristics  \nIn total, 623 participants from the Mom2B study completed the DERS -16 at 16 -25 \nweeks antepartum and were included in this study (see Figure 1). Sample characteristics are \nprovided in Table 1. Due to varying availability of surveys across peripartum periods, sample \nsizes differ for each analysis (see Table 1). Among those completing the EPDS, depressive \nsymptoms above the cut-off (score of ≥ 13) were noted in 18.9% at 24 -35 weeks and 15.5% \nat 36-42 weeks antepartum. Postpartum, EPDS scores (≥ 12) were observed as follows: 23.6% \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 8 \nat 1-4 weeks, 17.4% at 6-13 weeks, 16.7% at 14-23 weeks, 15.9% at 24-35 weeks, and 14.8% \nat 36-49 weeks, reflecting clinically relevant depressive symptoms.37,38 \nEmotion regulation remains stable over the peripartum  \nFor stability analysis, 199 participants filled in the DERS-16 for a second time at 17-25 \nweeks postpartum (see Figure 1). DERS-16 scores at 16-25 weeks antepartum were strongly \ncorrelated with scores at 17-25 weeks postpartum (r(197) = .655, p <.001) with no significant \nmean differences between periods (p = .076, see Supplementary Information).  \nEmotion regulation is robustly associated with peripartum depressive symptoms   \nRegression models (see  Table 2) showed that DERS -16 score at 16 -25 weeks \nantepartum (exposure) is significantly associated with peripartum EPDS scores (outcome). \nDERS-16 was significantly associated with EPDS scores until 14 -23 weeks postpartum in all \nthree regression models ( see Table  2: crude p-values < .001; adjusting for potential \nconfounders excluding EPDS antepartum p-values < .017, adjusting for potential confounders \nincluding EPDS antepartum p-values < .05). While DERS-16 was significantly associated with \nEPDS assessed at 24-35 weeks postpartum in the crude model, this association became non-\nsignificant with the coefficients attenuated towards the null when adjusting for potential \nconfounders (excluding EPDS antepartum: p = .111; including EPDS antepartum: p = .517). \nFor EPDS scores at 36 -49 weeks po stpartum, the association was significant in the crude \nmodel (p < .001) and the confounder-adjusted model (excluding EPDS antepartum: p = .018), \nbut non-significant after adjusting for EPDS antepartum (p = .196). Figure 2 shows all included \nregression coefficients (exposure and potential confounders) and color-coded their significant \npositive or negative association with EPDS score across the peripartum. All regression \ncoefficients and associated statistics for potential confounders are reported for the different \nregression models in Supplementary Table 1. \nEmotion regulation differs across PeriPD trajectories  \nOf the 623 participants, 134 completed the EPDS across all seven timepoints, enabling \nPeriPD trajectory classification. Compared to the complete EPDS responders, complete EPDS \nnon-responders registered later in pregnancy ( t(601) = -.2.69, p < .001), had a higher pre -\npregnancy BMI (t(614) = -.55, p = .041) and had more planned caesarean sections (X 2(3) = \n8.93, p = .030). No other differences were found (all p-values ≥ .078). Trajectories referred to: \nhealthy (45.5%), antepartum -only (7.5%), early postpartum -onset (26.9%), late postpartum -\nonset (6.0%), and persistent depression (14.2%; see Figure 1). Significant differences in \nantepartum DERS-16 scores were found between the PeriPD trajectory groups ( F(4,129) = \n26.68, p < .001, ηp2 = .45; see Figure 4). Post-hoc tests showed higher antepartum DERS-16 \nscores in early and late postpartum-onset trajectories compared to the healthy group (p = .017, \np = .018, respectively), with the persistent depression trajectory having higher DERS-16 scores \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 9 \nthan all other groups (all p-values ≤ .006). Supplementary Tables 2 and 3 provide descriptive \ninformation. \n  \nDiscussion \nThis Swedish national app -based cohort study  showed that self-reported emotion \nregulation (ER) remained relatively stable from pregnancy through the postpartum period. \nDifficulties in ER, assessed in the second trimester via the DERS-16, were strongly associated \nwith peripartum depression (PeriPD) symptoms up to  14-23 week postpartum, even after \nadjusting for potential confounders. This association, however, did not extend robustly beyond \nsix months postpartum when accounting for antepartum depression (AntePD) scores. Notably, \nwomen who would later meet the EPDS threshold for postpartum depression (PostPD) already \ndisplayed increased ER difficulties as early as the second trimester , pinpointing a possibility \nfor early identification of high-risk individuals. \nThe DERS -16 scores as reported in pregnancy and postpartum showed a strong \ncorrelation without significant mean changes, supporting its reliability for assessing ER across \nthe peripartum period. This aligns with previous findings on the stability of ER29 also during the \nperipartum period.19,24,47 While Coo et al. 24 reported overall stability of ER from pregnancy to \npostpartum and observed improvements in DERS subscales, our findings indicate a tendency \ntoward slightly higher, i.e. worse, DERS-16 scores four to six months postpartum, though not \nstatistically significant. This discrepancy may relate to the assessment timing differences (Coo \net al. third trimester, period of heightened bodily changes and symptoms as well as imminent \npsychosocial changes; current study second trimester, women may not yet be experiencing \nelevated stress to this extent) and ER assessment versions (Coo et al. used  an adapted \nversion of DERS48 and analyzed subscale scores; current study used DERS-16 total score). \nDespite the overall stability, both studies highlight subtle variability in ER that could be \naddressed through targeted interventions. Generally, our findings highlight DERS -16’s utility \nas a reliable tool for assessing ER difficulties across the peripartum.  \nER difficulties assessed in the second trimester were strongly associated with \ndepressive symptoms throughout the peripartum and up to six months postpartum, even after \ncontrolling for potential confounders, supporting previous evidence linking ER to \npsychopathology and mental health vulnerability. 12,49 Our findings are in line with previous \nstudies showing an association between emotion dysregulation and higher levels of AntePD \nand PostPD symptoms.16,20,22,23,50,51 Unlike prior studies that found no significant link between \nantepartum ER and PostPD23, our data show a robust association across multiple postpartum \ntimepoints. This association, however, weakened beyond six months postpartum, suggesting \nthe DERS-16’s sensitivity for depressive risk might be limited after this period. Our results \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 10 \nunderscore ER as an important factor in identifying PeriPD risk and support the clinical utility \nof the DERS-16 as a prognostic tool during pregnancy.  \nRemarkably, the early and late postpartum -onset depression trajectories reported \nsignificantly more ER difficulties during the second trimester, even while still below the \nthreshold for depression during the time of the ER assessment. This finding aligns with \nWikman et al. 9, who identified distinct characteristics among PeriPD trajectories before \nchildbirth, yet extending this work by demonstrating that these trajectories may differ in \npsychological abilities like ER. Recognizing emotion dysregulation as an early vulnerabili ty \nmarker for PostPD is particularly relevant for the late postpartum-onset trajectory, where many \ncases go undiagnosed, partly due to diagnostic criteria not acknowledging symptom onset \nbeyond six weeks postpartum.10,52 Thus, assessing ER difficulties during pregnancy with the \n16-item self-report scale could be of considerable value for healthcare providers. Contrary to \nour expectations, the antepartum-only depression trajectory showed no significant differences \nin DERS-16 scores compared to the healthy group, suggesting that women in the antepartum-\nonly trajectory may have had adaptive ER skills, limiting symptoms to pregnancy only. \nMoreover, our data imply that the antepartum -only trajectory might not be primarily linked to \nemotion dysregulation. However, this lack of difference in self-reported ER warrants replication, \npartly due to small sample size in the antepartum -only group. In contrast, the persistent \ntrajectory showed significantly higher ER  difficulties during pregnancy, with depressive \nsymptoms persisting throughout the peripartum period, indicating sustained vulnerability. Our \nstudy highlights the heterogeneity of PeriPD, challenging the traditional dichotomous view of \nthis condition. A nuanced understanding is vital for identifying trajectory or subgroup -specific \ncauses and risk factors.9 Ultimately, effectively communicating the distinct mental health risks \nand needs associated with different PeriPD trajectories, such as ER, to healthcare providers \nis essential9, paving the way for personalized medical approaches to prevention and treatment. \n \nAlthough this study features a large, population -based and well -characterized \nprospective sample, some limitations should be noted: First, the cohort’s overrepresentation \nof Swedish-born women with higher education may limit generalizability of findings, particularly \ngiven the higher prevalence of PeriPD among women from lower socioeconomic or minority \nbackgrounds.53,54 Second, high rates of self -reported history of mental illness potentially \nintroduces a level of selection bias, as individuals more attuned to mental health concerns may \nbe more likely to participate in a study on maternal mental health. Third, missing data and non-\nresponse at different timepoints, a common challenge of mobile health research 35, led to \nvariable sample size in our regression analyses, which could be linked to how well or poorly \nparticipants felt during the peripartum period. Also, dropout rates during later postpartum \ntimepoints increased. These issues, however, were mitigated by  maintaining a fairly large \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 11 \nsample size and ensuring similar background characteristics between responders and non -\nresponders. The EPDS, although a widely used screening tool, is not a diagnostic instrument \nand has been discussed to capture general psychological distress rather than specifically just \ndepressive symptoms.55-57 Also, we did not evaluate symptom severity in relation to clinically \ndiagnosed depression, nor account for potential treatment effects that might have altered \nsymptom trajectories. Instead, our goal was to examine the association between ER and the \nEPDS as a measure of mental health and well -being. Our results underscore ER’s role as a \ntransdiagnostic factor for mental health, highlighting it as a tangible t arget for prevention and \nintervention efforts. Finally, PeriPD is a multifactorial disorder8,58,59, with ER likely representing \njust one part of its complex etiology. While future research should approach PeriPD from \nmultiple perspectives, our study’s strength lies in addressing this complexity by controlling for \ndiverse known and available confounders in the Mom2B dataset. \n \nIn conclusion, this study emphasizes the significance of ER difficulties during the \nsecond trimester of pregnancy as an early and robust vulnerability marker for PeriPD \nsymptoms, particularly for cases progressing to PostPD. The findings endorse the DERS -16 \nas a practical screening tool for identifying peripartum mental health risks and guiding timely \ninterventions.26,27 Given that effective ER skills can be trained and strengthened during \npregnancy18,60,61, enhancing ER during pregnancy presents a promising avenue for prevention \nand intervention. Future research should evaluate the clinical utility of DERS-16 screenings \nand explore which PeriPD trajectories benefit most from ER -centered interventions. As a \nresilience factor, strengthened ER abilities can buffer stress, improve maternal mental health \nand ultimately support positive parent-child relationships and child development.18,22,23,31  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 12 \nAcknowledgements. We thank Richard Aubrey White for the guidance in the statistical  and \nvisualization aspects of the study and Andreas Frick for discussions on the use of instruments \nto assess emotional regulation.  \n \nAuthor Contribution. FW: Conceptualization; Methodology; Formal analysis; Investigation; \nVisualization; Writing – original draft. EF: Conceptualization; Validation; Writing – review & \nediting. BD: Conceptualization; Methodology; Funding acquisition; Supervision; Validation; \nWriting – review & editing. AS: Project administration; Conceptualization; Data acquisition; \nMethodology; Investigation; Funding acquisition; Resources; Supervision; Validation; Writing \n– review & editing. \n \nFunding. This project was funded by the German Research Foundation (DFG) as part of the \nInternational Research Training Group “Women’s Mental Health Across the Reproductive \nYears” (IRTG2804). Additionally, the Mom2B-project has received funding from the Swedish \nResearch Council (Gr ant numbers 2020 -01965), the Swedish Brain Foundation (Grant \nnumbers FO2021-0161, FO2022-0098), the Swedish state under the ALF-agreement, the Olle \nEngkvists Foundation (224 -0064), and the Swedish Association of Local Authorities and \nRegions (to the Department of Obstetrics and Gynaecology, Uppsala University). \n \nConflict of Interest Disclosure. The authors declare no competing interests. \n \nData Availability Statement . Datasets used in the present study are available upon \nreasonable request from the corresponding authors.   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 13 \nReferences \n1. Dagher, R. K., Bruckheim, H. E., Colpe, L. J., Edwards, E., & White, D. B. (2021). \nPerinatal depression: Challenges and opportunities.  J Womens Health , 30(2), 154 -\n159. https://doi.org/10.1089/jwh.2020.8862 \n2. Fransson, E., Örtenstrand, A., & Hjelmstedt, A. (2011). Antenatal depressive symptoms \nand preterm birth: a prospective study of a Swedish national sample.  Birth, 38(1), 10-\n16. https://doi.org/10.1111/j.1523-536X.2010.00441.x \n3. Iliadis, S. I., Skalkidou, A., Ranstrand, H., Georgakis, M. K., Axfors, C., & \nPapadopoulos, F. C. (2018). Self-harm thoughts postpartum as a marker for long-term \nmorbidity. Front Public Health, 6, 34. https://doi.org/10.3389/fpubh.2018.00034 \n4. Tronick, E., & Reck, C. (2009). Infants of depressed mothers.  Harvard review of \npsychiatry, 17(2), 147-156. https://doi.org/10.1080/10673220902899714 \n5. Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, \nT. (2005). Perinatal depression: a systematic review of prevalence and \nincidence. Obstet & Gynecol , 106(5 Part 1), 1071 -1083. \nhttps://doi.org/10.1097/01.AOG.0000183597.31630.db \n6. Underwood, L., Waldie, K., D’Souza, S., Peterson, E. R., & Morton, S. (2016). A review \nof longitudinal studies on antenatal and postnatal depression.  Arch Womens Ment \nHealth, 19, 711-720. https://doi.org/10.1007/s00737-016-0629-1 \n7. Altemus, M., Neeb, C. C., Davis, A., Occhiogrosso, M., Nguyen, T., & Bleiberg, K. L. \n(2012). Phenotypic differences between pregnancy-onset and postpartum-onset major \ndepressive disorder.  J Clin Psychiatry , 73(12), 14455. \nhttps://doi.org/10.4088/JCP.12m07693 \n8. Denckla, C. A., Mancini, A. D., Consedine, N. S., et al. (2018). Distinguishing \npostpartum and antepartum depressive trajectories in a large population-based cohort: \nthe impact of exposure to adversity and offspring gender.  Psychol Med, 48(7), 1139-\n1147. https://doi.org/10.1017/S0033291717002549 \n9. Wikman, A., Axfors, C., Iliadis, S. I., Cox, J., Fransson, E., & Skalkidou, A. (2019). \nCharacteristics of women with different perinatal depression trajectories.  J Neurosc \nRes 98(7), 1268-1282. https://doi.org/10.1002/jnr.24390 \n10. American Psychiatric Association, D. S. M. T. F., & American Psychiatric Association, \nD. S. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5, No. \n5). Washington, DC: American psychiatric association.  \n11. Bränn, E., Malavaki, C., Fransson, E., et al. (2021). Metabolic profiling indicates \ndiversity in the metabolic physiologies associated with maternal postpartum depressive \nsymptoms. Front Psychiatry, 12, 685656. https://doi.org/10.3389/fpsyt.2021.685656  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 14 \n12. Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies \nacross psychopathology: A meta -analytic review. Clin Psychol Rev , 30(2), 217 -237. \nhttps://doi.org/10.1016/j.cpr.2009.11.004 \n13. Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation \nand dysregulation: Development, factor structure, and initial validation of the difficulties \nin emotion regulation scale.  J Psychopathol Behav Assess  26, 41 -54. \nhttps://doi.org/10.1023/B:JOBA.0000007455.08539.94 \n14. Rammensee, R. A., Morawetz, C., & Basten, U. (2023). Individual differences in \nemotion regulation: Personal tendency in strategy selection is related to \nimplementation capacity and well-being. Emotion. \nhttps://doi.org/10.1037/emo0001234 \n15. Gingnell, M., Bannbers, E., Moes, H., et al. (2015). Emotion reactivity is increased 4-6 \nweeks postpartum in healthy women: a longitudinal fMRI study.  PLoS One , 10(6), \ne0128964. https://doi.org/10.1371/journal.pone.0128964 \n16. McDonald, H. M., Sherman, K. A., & Kasparian, N. A. (2021). A mediated model of \nmindful awareness, emotion regulation, and maternal mental health during pregnancy \nand postpartum.  Aust J Psychol , 73(3), 368 -380. \nhttps://doi.org/10.1080/00049530.2021.1908846 \n17. Penner, F., Bunderson, M., Bartz, C., Brooker, R. J., & Rutherford, H. J. (2022). Emotion \nregulation strategies and perceived stress during pregnancy in expectant mothers and \nfathers. J Reprod Infant Psychol , 42(3), 410 -423. \nhttps://doi.org/10.1080/02646838.2022.2110224 \n18. Penner, F., & Rutherford, H. J. (2022). Emotion regulation during pregnancy: A call to \naction for increased research, screening, and intervention.  Arch Womens Ment \nHealth, 25(2), 527-531. https://doi.org/10.1007/s00737-022-01204-0 \n19. Conradt, E., Shakiba, N., Ostlund, B., et al. (2020). Prenatal maternal hair cortisol \nconcentrations are related to maternal prenatal emotion dysregulation but not \nneurodevelopmental or birth outcomes.  Dev Psychobiol , 62(6), 758 -767. \nhttps://doi.org/10.1002/dev.21952 \n20. Kalmbach, D. A., Roth, T., Cheng, P., Ong, J. C., Rosenbaum, E., & Drake, C. L. (2020). \nMindfulness and nocturnal rumination are independently associated with symptoms of \ninsomnia and depression during pregnancy.  Sleep Health , 6(2), 185 -191. \nhttps://doi.org/10.1016/j.sleh.2019.11.011 \n21. Bradizza, C. M., Stasiewicz, P. R., Zhuo, Y., et al. (2017). Smoking cessation for \npregnant smokers: Development and pilot test of an emotion regulation treatment \nsupplement to standard smoking cessation for negative affect smokers.  Nicotine Tob \nRes 19(5), 578-584. https://doi.org/10.1093/ntr/ntw398 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 15 \n22. Lin, B., Kaliush, P. R., Conradt, E., et al. (2019). Intergenerational transmission of \nemotion dysregulation: Part I. Psychopathology, self -injury, and parasympathetic \nresponsivity among pregnant women.  Dev Psychopathol , 31(3), 817 -831. \nhttps://doi.org/10.1017/S0954579419000336 \n23. Coo, S., García, M. I., Prieto, F., & Medina, F. (2022). The role of interpersonal \nemotional regulation on maternal mental health. J Reprod Infant Psychol, 40(1), 3-21. \nhttps://doi.org/10.1080/02646838.2020.1825657 \n24. Marques, R., Monteiro, F., Canavarro, M. C., & Fonseca, A. (2018). The role of emotion \nregulation difficulties in the relationship between attachment representations and \ndepressive and anxiety symptoms in the postpartum period.  J Affect Disord, 238, 39-\n46. https://doi.org/10.1016/j.jad.2018.05.013 \n25. Paley, B., & Hajal, N. J. (2022). Conceptualizing emotion regulation and coregulation \nas family-level phenomena. Clinical Child and Family Psychology Review , 25(1), 19-\n43. https://doi.org/10.1007/s10567-022-00378-4  \n26. Barrett, E. N., Frey, B. N., Streiner, D. L., et al. (2023). Psychometric properties of the \ndifficulties in emotion regulation Scale in a perinatal sample. J Reprod Infaant Psychol, \n1-20. https://doi.org/10.1080/02646838.2023.22276489 \n27. Goldstein, B. L., Briggs-Gowan, M. J., Greene, C. C., Chang, R., & Grasso, D. J. (2021). \nAn Item Response Theory examination of the original and short forms of the Difficulties \nin Emotion Regulation Scale (DERS) in pregnant women. J Clin Psychol, 77(7), 1591-\n1606. https://doi.org/10.1002/jclp.23167 \n28. Hallion, L. S., Steinman, S. A., Tolin, D. F., & Diefenbach, G. J. (2018). Psychometric \nproperties of the Difficulties in Emotion Regulation Scale (DERS) and its short forms in \nadults with emotional disorders.  Front Psychol , 9, 539. \nhttps://doi.org/10.3389/fpsyg.2018.00539 \n29. Bjureberg, J., Ljótsson, B., Tull, M. T., et al. (2016). Development and validation of a \nbrief version of the difficulties in emotion regulation scale: the DERS -16. J \nPsychopathol Behav Assess, 38, 284-296. https://doi.org/10.1007/s10862-015-9514-x \n30. Hajal, N. J., & Paley, B. (2020). Parental emotion and emotion regulation: A critical \ntarget of study for research and intervention to promote child emotion socialization. Dev \nPsychol, 56(3), 403. https://doi.org/10.1037/dev0000864 \n31. Sacher, J., Chechko, N., Dannlowski, U., Walter, M., & Derntl, B. (2020). The \nperipartum human brain: current understanding and future perspectives.  Front \nNeuroendocrinol, 59, 100859. https://doi.org/10.1016/j.yfrne.2020.100859 \n32. Bilal, A. M., Fransson, E., Bränn, E., et al. (2022). Protocol: Predicting perinatal health \noutcomes using smartphone -based digital phenotyping and machine learning in a \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 16 \nprospective Swedish cohort (Mom2B): study protocol.  BMJ Open , 12(4). \nhttps://doi.org/10.1136/bmjopen-2021-059033 \n33. Deogan, C., Abrahamsson, K., Mannheimer, L., & Björkenstam, C. (2022). Having a \nchild without wanting to? Estimates and contributing factors from a population -based \nsurvey in Sweden.  Scand J Public Health , 50(2), 215 -222. \nhttps://doi.org/10.1177/1403494820965762 \n34. Kopp Kallner, H., Thunell, L., Brynhildsen, J., Lindeberg, M., & Gemzell Danielsson, K. \n(2015). Use of contraception and attitudes towards contraceptive use in Swedish \nwomen-a nationwide survey.  PLoS one , 10(5), e0125990. \nhttps://doi.org/10.1371/journal.pone.0125990 \n35. Goldberg, S. B., Bolt, D. M., & Davidson, R. J. (2021). Data missing not at random in \nmobile health research: Assessment of the problem and a case for sensitivity \nanalyses. J Med Internet Res, 23(6), e26749. https://doi.org/10.2196/26749  \n36. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: \ndevelopment of the 10 -item Edinburgh Postnatal Depression Scale.  Br J \nPsychiatry, 150(6), 782-786. https://doi.org/10.1192/bjp.150.6.782 \n37. Rubertsson, C., Börjesson, K., Berglund, A., Josefsson, A., & Sydsjö, G. (2011). The \nSwedish validation of Edinburgh postnatal depression scale (EPDS) during \npregnancy. Nord J Psychiatry, 65(6), 414-418. \nhttps://doi.org/10.3109/08039488.2011.590606 \n38. Wickberg, B., & Hwang, C. P. (1996). The Edinburgh postnatal depression scale: \nvalidation on a Swedish community sample.  Acta Psychiatr Scand , 94(3), 181 -184. \nhttps://doi.org/10.1111/j.1600-0447.1996.tb09845.x \n39. Andersson, S., Bathula, D. R., Iliadis, S. I., Walter, M., & Skalkidou, A. (2021). \nPredicting women with depressive symptoms postpartum with machine learning \nmethods. Sci Rep, 11(1), 7877. https://doi.org/10.1038/s41598-021-86368-y  \n40. Hildingsson, I., Rubertsson, C., Karlström, A., & Haines, H. (2018). Exploring the Fear \nof Birth Scale in a mixed population of women of childbearing age —a Swedish pilot \nstudy. Women Birth, 31(5), 407-413. https://doi.org/10.1016/j.wombi.2017.12.005 \n41. Aiena, B. J., Baczwaski, B. J., Schulenberg, S. E., & Buchanan, E. M. (2015). \nMeasuring resilience with the RS–14: A tale of two samples. J Pers Assess, 97(3), 291-\n300. https://doi.org/10.1080/00223891.2014.951445 \n42. Wagnild, G. M., & Young, H. M. (1993). Development and psychometric evaluation of \nthe resilience scale. J Nurs Meas, 1(2), 165-178. \n43. Antonovsky, A. (1993). The structure and properties of the sense of coherence \nscale. Soc Sci Med, 36(6), 725-733. https://doi.org/10.1016/0277-9536(93)90033-z \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 17 \n44. Eriksson, M., & Lindström, B. (2005). Validity of Antonovsky’s sense of coherence \nscale: a systematic review.  J Epidemiol Community Health,  59(6), 460 -466. \nhttps://doi.org/10.1136/jech.2003.018085 \n45. Boyce, P., Hickey, A., Gilchrist, J., & Talley, N. J. (2001). The development of a brief \npersonality scale to measure vulnerability to postnatal depression. Arch Womens Ment \nHealth, 3, 147-153. https://doi.org/10.1007/s007370170012  \n46. Dennis, C. L., & Boyce, P. (2004). Further psychometric testing of a brief personality \nscale to measure vulnerability to postpartum depression.  J Psychosom Obstet \nGynaecol, 25(3-4), 305-311. https://doi.org/10.1080/01674820400017962 \n47. D’Avanzato, C., Joormann, J., Siemer, M., & Gotlib, I. H. (2013). Emotion regulation in \ndepression and anxiety: Examining diagnostic specificity and stability of strategy \nuse. Cognit Ther Res, 37, 968-980. https://doi.org/https://doi.org/10.1007/s10608-013-\n9537-0 \n48. Hervás, G., & Jódar, R. (2008). Adaptación al castellano de la Escala de Dificultades \nen la Regulación Emocional. Clínica y salud, 19(2), 139-156. \n49. Lincoln, T. M., Schulze, L., & Renneberg, B. (2022). The role of emotion regulation in \nthe characterization, development and treatment of psychopathology.  Nat Rev \nPsychol, 1(5), 272-286. https://doi.org/10.1038/s44159-022-00040-4 \n50. Haga, S. M., Ulleberg, P., Slinning, K., Kraft, P., Steen, T. B., & Staff, A. (2012). A \nlongitudinal study of postpartum depressive symptoms: multilevel growth curve \nanalyses of emotion regulation strategies, breastfeeding self -efficacy, and social \nsupport. Arch Womens Ment Health, 15, 175-184. https://doi.org/10.1007/s00737-012-\n0274-2 \n51. Ifeagwazi, C. M., Obiajulu, B. M., Chukwuorji, J. C., & Ndukaihe, I. L. (2021). Emotion \ndysregulation robustly predicts depressive symptoms above and beyond life events \nand social support in sub -saharan African pregnant women.  Womens Reprod \nHealth, 8(1), 29-43. https://doi.org/10.1080/23293691.2020.1861414 \n52. World Health Organization. (2016).  International statistical classification of diseases \nand related health problems (10th ed.). https://www.who.int/classifications/icd/en/ \n53. Falah-Hassani, K., Shiri, R., Vigod, S., & Dennis, C. L. (2015). Prevalence of \npostpartum depression among immigrant women: a systematic review and meta -\nanalysis. J Psychiatr Res, 70, 67-82. https://doi.org/10.1016/j.jpsychires.2015.08.010  \n54. Halbreich, U., & Karkun, S. (2006). Cross-cultural and social diversity of prevalence of \npostpartum depression and depressive symptoms.  J Affect Disord , 91(2-3), 97 -111. \nhttps://doi.org/10.1016/j.jad.2005.12.051  \n55. Judd, F., Lorimer, S., Thomson, R. H., & Hay, A. (2019). Screening for depression with \nthe Edinburgh Postnatal Depression Scale and finding borderline personality \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 18 \ndisorder. Aust N Z J Psychiatry , 53(5), 424 -432. \nhttps://doi.org/10.1177/0004867418804067 \n56. Lautarescu, A., Victor, S., Lau-Zhu, A., Counsell, S. J., Edwards, A. D., & Craig, M. C. \n(2022). The factor structure of the Edinburgh Postnatal Depression Scale among \nperinatal high-risk and community samples in London.  Arch Womens Ment Health, 1-\n13.  https://doi.org/10.1007/s00737-021-01153-0  \n57. Rondung, E., Massoudi, P., Nieminen, K., et al. (2024). Identification of depression and \nanxiety during pregnancy: A systematic review and meta-analysis of test accuracy. Acta \nObstet Gnyecol Scand, 103(3), 423-436. https://doi.org/10.1111/aogs.14734  \n58. Bloch, M., Rotenberg, N., Koren, D., & Klein, E. (2005). Risk factors associated with \nthe development of postpartum mood disorders.  J Affect Disord , 88(1), 9 -18. \nhttps://doi.org/10.1016/j.jad.2005.04.007  \n59. Giallo, R., Pilkington, P., McDonald, E., Gartland, D., Woolhouse, H., & Brown, S. \n(2017). Physical, sexual and social health factors associated with the trajectories of \nmaternal depressive symptoms from pregnancy to 4 years postpartum. Soc Psychiatry \nPsychiatr Epidemiol, 52, 815-828. https://doi.org/10.1007/s00127-017-1387-8  \n60. Agako, A., Donegan, E., McCabe, R. E., Frey, B. N., Streiner, D., & Green, S. (2021). \nThe role of emotion dysregulation in cognitive behavioural group therapy for perinatal \nanxiety: Results from a randomized controlled trial and routine clinical care.  J Affect \nDisord, 292, 517-525. https://doi.org/10.1016/j.jad.2021.05.084  \n61. Agako, A., Burckell, L., McCabe, R. E., et al. (2023). A pilot study examining the \neffectiveness of a short -term, DBT informed, skills group for emotion dysregulation \nduring the perinatal period.  Psychol Serv , 20(3), 697. \nhttps://doi.org/10.1037/ser0000662   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 19 \nTable 1. Characteristics of study sample.   \nCharacteristics N (%) \nResponders \nMean \n(SD) \nRange \nMin-Max \nTotal 623 (100%)   \nAge (years)  623 (100%) 31.66 \n(4.57) 19-44 \nPre-pregnancy BMI (kg/m2)  616 (98.9%) 26.07 \n(6.04) 14-69 \nEducation 623 (100%)   \nUniversity level education  423 (67.9%)   \nRelationship status  623 (100%)   \nPartner, not cohabiting   606 (97.3%)   \nPartner, cohabiting   585 (93.9%)   \nPartner violence  596 (95.7%)   \nCurrent partner violence  11 (1.8%)   \nPrevious partner violence 140 (23.5%)    \nMental health history 623 (100%)   \nDepression history (self-reported) 340 (54.6%)   \nProfessional help  276 (44.3%)   \nAnxiety history (self-reported) 275 (44.2%)   \nProfessional help 201 (32.3%)   \nFemale-specific mental health 618 (99.2%)   \nTreatment for premenstrual disorders  62 (10%)   \nMood swings from oral contraceptives  308 (49.8%)   \nSubstance use  617 (99.2%)   \nAlcohol, 3 months before pregnancy  478 (77.5%)   \nAlcohol, ≥ 7 glasses/week  \n3 months before pregnancy 13 (2.7%)   \nSmoking, 3 months before pregnancy 85 (13.8%)   \nSnus, 3 months before pregnancy 112 (18.0%)   \nPregnancy-related variables    \nPregnancy week at registration to Mom2B study 603 (96.79%) 31.66 \n(4.57) 2-26 \nParity 606 (97.3%)   \nPrimiparous  234 (38.6%)   \nHistory of pregnancy loss  610 (97.9%)   \nPrevious pregnancy loss  206 (33.8%)   \nFear of Birth Scale \n(mean total score 13-42 w antepartum) 608 (97.6%) 38.31 \n(25.49) 0-100 \nDelivery-related variables    \nDelivery experience 0-2 w postpartum \n(scale from 0 = negative to 100 = positive) 357 (57.3%) 76.6 \n(20.16) 0-100 \nMode of delivery 357 (57.3%)   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 20 \nVaginal delivery 263 (73.7%)   \nAssisted vacuum delivery 29 (8.1%)   \nPlanned caesarean section 29 (8.1%)   \nEmergency caesarean section 36 (10.1%)   \nPostpartum-related variables    \nNeonatal issues  356 (57.1%)   \nReported neonatal issues up to 0-2 w \npostpartum 43 (12.1%)    \nBreastfeeding  340 (54.6%)   \nFull/partly   337 (99.1%)    \nPsychometric scales    \nDERS-16 (total score) 16-25 w antepartum 623 (100%) 32.42 \n(13.03) 16-76 \nDERS-16 (total score) 17-25 w antepartum  199 (31.9%) 32.45 \n(13.67) 16-73 \nSOC-13 (total score) 18-42 w antepartum 565 (90.7%) 55.61 \n(6.70) 31-78 \nRS-14 (total score) 20-42 w antepartum  550 (88.3%) 75.41 \n(12.36) 28-98 \nVPSQ (total score) 32-42 w antepartum 420 (67.4%) 26.95 \n(4.09) 19-41 \nEPDS (total score) 12-22 w antepartum 545 (87.5%) 7.45 \n(5.19) 0-27 \nEPDS (total score) 24-34 w antepartum 518 (83.1%) 7.50 \n(5.19) 0-26 \nEPDS (total score) 36-42 w antepartum 373 (59.9%) 6.82 \n(5.29) 0-24 \nEPDS (total score) 1-4 w postpartum 339 (54.4%) 7.99 \n(5.47) 0-26 \nEPDS (total score) 6-13 w postpartum 282 (45.23%) 6.34 \n(5.06) 0-24 \nEPDS (total score) 14-23 w postpartum 221 (35.5%) 6.38 \n(5.16) 0-25 \nEPDS (total score) 24-35 w postpartum 151 (24.2%) 5.37 \n(5.09) 0-21 \nEPDS (total score) 36-49 w postpartum 81 (13.0%) 5.62 \n(5.03) 0-19 \nw = weeks \n \nNote. Results are presented as frequencies and relative frequencies within the subset of \nsurvey-responders and if applicable additionally  means (standard deviation, SD). BMI: Body \nmass index; DERS-16: Deficits in Emotion Regulation Scale-16; EPDS: Edinburgh Postnatal \nDepression Scale; RS -14: Resilience Scale -14; SOC -13: Sense of Coherence -13; VPSQ: \nVulnerable Personality Style Questionnaire.  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 21 \nTable 2. Regression coefficients and 95% confidence interval of Deficits of Emotion Regulation \nScale-16 (DERS -16) 16 -25 weeks antepartum (exposure) in linear regression models on \nEdinburgh Postnatal Depression Scale (EPDS) across the peripartum period (outcome).  \n(Outcome) \n \nEPDS total score \nacross the \nperipartum period \n(1) \n \nUnadjusted \n(2) \n \nAdjusted for  \npotential confounders \n– EPDS total score  \n12-22 w antepartum \n(3) \n \nAdjusted for  \npotential confounders \n+ EPDS total score  \n12-22 w antepartum \n  beta coefficients for DERS-16 total score 16-25 w antepartum \n24-34 w antepartum .22 (.19 to .25) *** .15 (.11 to .19) *** .15 (.11 to .19) *** \n36-42 w antepartum .23 (.19 to .26) *** .15 (.11 to .20) *** .15 (.11 to .20) *** \nBIRTH  \n1-4 w postpartum .17 (.13 to .22) *** .08 (.03 to .13) *** .06 (.00 to .11) * \n6-13 w postpartum .18 (.13 to .22) *** .09 (.04 to .14) *** .06 (.00 to .11) * \n14-23 w postpartum .21 (.17 to .26) *** .15 (.09 to .20) *** .10 (.04 to .15) *** \n24-35 w postpartum .15 (.10 to .21) *** .06 (-.01 to .13) + .03 (-.05 to .10) ns \n36-49 w postpartum .22 (.15 to .29) *** .09 (.02 to .16) * .04 (-.02 to .11) ns \nnsp  ≥ .196, +p = .111, *p < .050, ***p ≤ .001; w: weeks \n \nNote. Models are corrected for (1) no other potential confounders (2) potential confounders \nexcluding EPDS total score 12-22 weeks antepartum and (3) potential confounders including \nEPDS total score 12 -22 weeks antepartum. Results for all beta coefficients can b e found in \nSupplementary Table 1.   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 22 \nFigure 1. Flowchart of included participants in the study. \nNote. Data for the present study were derived from January 2022 to April 2024 from the  \nprospective Swedish national cohort study Mom2B ( 35) as the Difficulties in Emotion \nRegulation Scale-16 (32) was introduced from May 2022 and was available for participants at \n16-25 weeks antepartum.   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 23 \nFigure 2.  Regression coefficients in linear regression models on Edinburgh Postnatal \nDepression Scale (EPDS) total score across peripartum (outcome).  \n \nNote. A. Model 2 with Deficits of Emotion Regulation Scale -16 (DERS -16) 16 -25 weeks \nantepartum (exposure) and other potential confounders excluding EPDS total score 12 -22 \nweeks antepartum. B. Model 3 with DERS-16 16-25 weeks antepartum (exposure) and other \npotential confounders including EPDS total score 12 -22 weeks antepartum. Heatmaps show \nregressors and their respective coefficient value on EPDS total scores across peripartum in \nthe tiles. The color of the tiles is dependent on the regressors’ significance and d irection of \nassociation (positive or negative). DERS -16 16-25 ap: Deficits of Emotion Regulation Scale -\n16 total score at 16-25 weeks antepartum; BMI: pre-pregnancy body-mass-index; University: \nuniversity level education (vs less); Pregnancy loss: pregnancy loss history  (vs never); \nDepression history: self-reported depression history with professional help (vs no); PMS: past \ntreatment for premenstrual disorder (vs never); OC mood: mental health issues due to oral \ncontraceptives (vs never); FOBS  13-42 ap: Fear of Birth Scale, mean total score  at 13-42 \nweeks antepartum; RS -14 20-42 ap : Resilience Scale -14 total score  at 20-42 weeks \nantepartum; SOC-13 18-42 ap: Sense of coherence-13 total score 18-42 weeks antepartum; \nVPSQ 32-42 ap : Vulnerable Personality Style Questionnaire total score at 32-42 weeks \nantepartum; Delivery experience: delivery experience at 0-2 weeks postpartum; Neonatal \nissues 0-2 pp: neonatal issues up to two  weeks postpartum (vs none). EPDS 12 -22 ap: \nEdinburgh Postnatal Depression Scale total score at 12-22 weeks antepartum.   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint \n\nEMOTION REGULATION ASSOCIATED WITH PERIPARTUM DEPRESSION 24 \nFigure 3. Peripartum depression trajectories and differences in Deficits of Emotion \nRegulation Scale-16 (DERS-16) total score.   \n \nNote. A. Edinburgh Postnatal Depression Scale (EPDS) mean total scores for each \nassessment period across peripartum shown for five distinct peripartum depression trajectory \ngroups. The overall EPDS mean score across the groups is represented by the black dashed \nline. The grey reference lines indicate the EPDS cut -off score for depression with a score of \n13 (dotted) used in antepartum and score of 12 (solid) used in postpartum.  B. Differences in \nin Deficits of Emotion Regulation Scale -16 (DERS -16) mean total  scores at 16 -25 weeks \nantepartum (N = 134) between the five distinct peripartum depression trajectory groups. Boxes \nshow upper and lower quartile values with the median indicated as bold line. Whiskers show \nminimum and maximum scores. *p < .005, ***p < .001.  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 13, 2024. ; https://doi.org/10.1101/2024.11.13.24317233doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}