Association of Postpartum Depression with Maternal Suicide: A Nationwide Population-Based Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Data Sources
2.2. Ethical Approval
2.3. Study and Comparison Cohorts
2.4. Statistical Analysis
3. Results
3.1. Clinical Characteristics
3.2. Cumulative Risk of Suicide
3.3. Factors Associated with Suicide
4. Discussion
4.1. Suicide and Subclinical Depression
4.2. Suicide and Subclinical Anxiety
4.3. Suicide and Age
4.4. Suicide and Season
4.5. Mean Time to Suicide
4.6. PDD and Physical Diseases
4.7. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Cohort | Delivery with PPD | Delivery without PPD | Without Delivery | |||||
---|---|---|---|---|---|---|---|---|
Variables | n | % | n | % | p | n | % | p |
Total | 2882 | 33.33 | 5764 | 66.67 | 5764 | 66.67 | ||
Suicide | <0.001 | <0.001 | ||||||
Without | 2592 | 89.94 | 5751 | 99.77 | 5754 | 99.83 | ||
With | 290 | 10.06 | 13 | 0.23 | 10 | 0.17 | ||
Age (mean ± SD, years) | 31.25 ± 9.76 | 33.02 ± 7.28 | <0.001 | 33.07 ± 7.39 | <0.001 | |||
Age groups (years) | <0.001 | <0.001 | ||||||
≤20 | 131 | 4.55 | 296 | 5.14 | 293 | 5.08 | ||
21–30 | 1622 | 56.28 | 3202 | 55.55 | 3223 | 55.92 | ||
31–34 | 458 | 15.89 | 1141 | 19.80 | 1198 | 20.78 | ||
35–37 | 244 | 8.47 | 514 | 8.92 | 373 | 6.47 | ||
38–40 | 197 | 6.84 | 257 | 4.46 | 281 | 4.88 | ||
41–43 | 126 | 4.37 | 102 | 1.77 | 98 | 1.70 | ||
≥44 | 104 | 3.61 | 252 | 4.37 | 298 | 5.17 | ||
Insured premium (NT$) | 0.991 | 0.979 | ||||||
<18,000 | 2527 | 87.68 | 5052 | 87.65 | 5060 | 87.79 | ||
18,000–34,999 | 247 | 8.57 | 498 | 8.64 | 493 | 8.55 | ||
≥35,000 | 108 | 3.75 | 214 | 3.71 | 211 | 3.66 | ||
HTN | <0.001 | <0.001 | ||||||
Without | 2678 | 92.92 | 5669 | 98.35 | 5653 | 98.07 | ||
With | 204 | 7.08 | 95 | 1.65 | 111 | 1.93 | ||
DM | <0.001 | <0.001 | ||||||
Without | 2714 | 94.17 | 5641 | 97.87 | 5657 | 98.14 | ||
With | 168 | 5.83 | 123 | 2.13 | 107 | 1.86 | ||
Hyperlipidemia | <0.001 | <0.001 | ||||||
Without | 2804 | 97.29 | 5729 | 99.39 | 5723 | 99.29 | ||
With | 78 | 2.71 | 35 | 0.61 | 41 | 0.71 | ||
COPD | 0.001 | 0.151 | ||||||
Without | 2827 | 98.09 | 5707 | 99.01 | 5678 | 98.51 | ||
With | 55 | 1.91 | 57 | 0.99 | 86 | 1.49 | ||
CKD | <0.001 | 0.002 | ||||||
Without | 2866 | 99.44 | 5757 | 99.88 | 5755 | 99.84 | ||
With | 16 | 0.56 | 7 | 0.12 | 9 | 0.16 | ||
IHD | 0.073 | 0.392 | ||||||
Without | 2813 | 97.61 | 5660 | 98.20 | 5643 | 97.90 | ||
With | 69 | 2.39 | 104 | 1.80 | 121 | 2.10 | ||
CHD | 0.804 | 0.054 | ||||||
Without | 2877 | 99.83 | 5752 | 99.79 | 5739 | 99.57 | ||
With | 5 | 0.17 | 12 | 0.21 | 25 | 0.43 | ||
Stroke | <0.001 | <0.001 | ||||||
Without | 2820 | 97.85 | 5733 | 99.46 | 5725 | 99.32 | ||
With | 62 | 2.15 | 31 | 0.54 | 39 | 0.68 | ||
Cancer | 0.517 | 0.317 | ||||||
Without | 2803 | 97.26 | 5620 | 97.50 | 5583 | 96.86 | ||
With | 79 | 2.74 | 144 | 2.50 | 181 | 3.14 | ||
Anxiety | <0.001 | <0.001 | ||||||
Without | 2549 | 88.45 | 5746 | 99.69 | 5725 | 99.32 | ||
With | 333 | 11.55 | 18 | 0.31 | 39 | 0.68 | ||
Depression | <0.001 | <0.001 | ||||||
Without | 1664 | 57.74 | 5737 | 99.53 | 5718 | 99.20 | ||
With | 1218 | 42.26 | 27 | 0.47 | 46 | 0.80 | ||
Obesity | 0.088 | 0.088 | ||||||
Without | 2872 | 99.65 | 5755 | 99.84 | 5755 | 99.84 | ||
With | 10 | 0.35 | 9 | 0.16 | 9 | 0.16 | ||
Season | <0.001 | 0.005 | ||||||
Spring | 705 | 24.46 | 1319 | 22.88 | 1302 | 22.59 | ||
Summer | 742 | 25.75 | 1408 | 24.43 | 1493 | 25.90 | ||
Autumn | 820 | 28.45 | 1511 | 26.21 | 1555 | 26.98 | ||
Winter | 615 | 21.34 | 1526 | 26.47 | 1414 | 24.53 | ||
Location | <0.001 | <0.001 | ||||||
Northern Taiwan | 1081 | 37.51 | 2624 | 45.52 | 2658 | 46.11 | ||
Middle Taiwan | 767 | 26.61 | 1662 | 28.83 | 1771 | 30.73 | ||
Southern Taiwan | 806 | 27.97 | 1182 | 20.51 | 1012 | 17.56 | ||
Eastern Taiwan | 213 | 7.39 | 283 | 4.91 | 294 | 5.10 | ||
Outlets islands | 15 | 0.52 | 13 | 0.23 | 29 | 0.50 | ||
Urbanization level | <0.001 | <0.001 | ||||||
1 (The highest) | 914 | 31.71 | 2180 | 37.82 | 2141 | 37.14 | ||
2 | 1300 | 45.11 | 2522 | 43.75 | 2502 | 43.41 | ||
3 | 247 | 8.57 | 467 | 8.10 | 537 | 9.32 | ||
4 (The lowest) | 421 | 14.61 | 595 | 10.32 | 584 | 10.13 | ||
Level of care | <0.001 | <0.001 | ||||||
Hospital center | 951 | 33.00 | 2127 | 36.90 | 2158 | 37.44 | ||
Regional hospital | 1362 | 47.26 | 2266 | 39.31 | 2435 | 42.24 | ||
Local hospital | 569 | 19.74 | 1371 | 23.79 | 1171 | 20.32 |
Delivery with PPD vs. Delivery without PPD (Reference) | Delivery with PPD vs. without Delivery (Reference) | |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Variables | Crude HR | 95% CI | 95% CI | p | Adjusted HR | 95% CI | 95% CI | p | Crude HR | 95% CI | 95% CI | p | Adjusted HR | 95% CI | 95% CI | p |
Cohort | ||||||||||||||||
Study cohort | 22.958 | 8.394 | 62.785 | <0.001 | 18.743 | 6.667 | 52.689 | <0.001 | 26.697 | 8.421 | 84.638 | <0.001 | 19.300 | 5.977 | 62.255 | <0.001 |
Comparison cohort 1/2 | Reference | Reference | Reference | Reference | ||||||||||||
Age groups (yrs) | ||||||||||||||||
≤20 | Reference | Reference | Reference | Reference | ||||||||||||
21–30 | 0.446 | 0.177 | 1.124 | 0.091 | 0.606 | 0.237 | 1.549 | 0.304 | 0.430 | 0.171 | 1.086 | 0.078 | 0.595 | 0.233 | 1.524 | 0.288 |
31–34 | 0.214 | 0.078 | 0.588 | 0.003 | 0.384 | 0.136 | 1.078 | 0.072 | 0.323 | 0.119 | 0.873 | 0.028 | 0.441 | 0.159 | 1.222 | 0.119 |
35–37 | 0.191 | 0.062 | 0.588 | 0.004 | 0.449 | 0.141 | 1.430 | 0.181 | 0.314 | 0.105 | 0.941 | 0.040 | 0.555 | 0.159 | 1.717 | 0.313 |
38–40 | 0.160 | 0.046 | 0.558 | 0.004 | 0.211 | 0.059 | 0.751 | 0.017 | 0.091 | 0.022 | 0.380 | 0.001 | 0.124 | 0.029 | 0.534 | 0.005 |
41–43 | 0.188 | 0.050 | 0.700 | 0.013 | 0.222 | 0.057 | 0.860 | 0.031 | 0.191 | 0.051 | 0.717 | 0.015 | 0.217 | 0.056 | 0.851 | 0.030 |
≥44 | 0.180 | 0.066 | 0.492 | 0.001 | 0.183 | 0.065 | 0.516 | <0.001 | 0.175 | 0.064 | 0.477 | 0.001 | 0.178 | 0.063 | 0.500 | <0.001 |
Insured premium (NT$) | ||||||||||||||||
<18,000 | Reference | Reference | Reference | Reference | ||||||||||||
18,000–34,999 | 0.743 | 0.104 | 5.333 | 0.768 | 0.578 | 0.074 | 4.505 | 0.602 | 0.579 | 0.081 | 4.160 | 0.589 | 0.573 | 0.074 | 4.457 | 0.596 |
≥35,000 | 1.921 | 0.267 | 13.778 | 0.501 | 4.948 | 0.635 | 38.589 | 0.122 | 2.901 | 0.405 | 20.815 | 0.280 | 5.341 | 0.671 | 42.479 | 0.110 |
HTN | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.174 | 0.025 | 1.248 | 0.083 | 0.372 | 0.049 | 2.836 | 0.342 | 0.163 | 0.023 | 1.166 | 0.072 | 0.376 | 0.049 | 2.871 | 0.347 |
DM | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.203 | 0.029 | 1.459 | 0.114 | 0.373 | 0.498 | 2.853 | 0.344 | 0.193 | 0.027 | 1.387 | 0.104 | 0.398 | 0.051 | 3.088 | 0.380 |
Hyperlipidemia | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.000 | - | - | 0.306 | 0.000 | - | - | 0.946 | 0.000 | - | - | 0.270 | 0.000 | - | - | 0.955 |
COPD | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.498 | 0.069 | 3.571 | 0.490 | 0.578 | 0.072 | 4.630 | 0.606 | 0.405 | 0.056 | 2.902 | 0.370 | 0.568 | 0.071 | 4.526 | 0.594 |
CKD | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.000 | - | - | 0.641 | 0.000 | - | - | 0.971 | 0.000 | - | - | 0.581 | 0.000 | - | - | 0.974 |
IHD | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.663 | 0.093 | 4.758 | 0.683 | 1.164 | 0.156 | 8.688 | 0.861 | 0.497 | 0.069 | 3.571 | 0.490 | 1.146 | 0.153 | 8.564 | 0.873 |
CHD | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.000 | - | - | 0.649 | 0.000 | - | - | 0.968 | 0.000 | - | - | 0.572 | 0.000 | - | - | 0.973 |
Stroke | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 1.617 | 0.399 | 6.562 | 0.484 | 2.314 | 0.537 | 9.969 | 0.250 | 1.055 | 0.261 | 4.281 | 0.913 | 2.210 | 0.511 | 9.546 | 0.276 |
Cancer | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.257 | 0.036 | 1.843 | 0.179 | 0.591 | 0.081 | 4.342 | 0.606 | 0.235 | 0.033 | 1.683 | 0.151 | 0.636 | 0.087 | 4.681 | 0.657 |
Anxiety | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 3.185 | 1.829 | 5.547 | <0.001 | 1.353 | 1.040 | 2.473 | 0.034 | 2.727 | 1.569 | 4.738 | <0.001 | 1.337 | 1.004 | 2.443 | 0.047 |
Depression | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 5.131 | 3.405 | 7.733 | <0.001 | 2.689 | 1.689 | 4.281 | <0.001 | 4.849 | 3.225 | 7.292 | <0.001 | 2.876 | 1.805 | 4.584 | <0.001 |
Obesity | ||||||||||||||||
Without | Reference | Reference | Reference | Reference | ||||||||||||
With | 0.000 | - | - | 0.742 | 0.000 | - | - | 0.975 | 0.000 | - | - | 0.595 | 0.000 | - | - | 0.973 |
Season | ||||||||||||||||
Spring | Reference | Reference | Reference | Reference | ||||||||||||
Summer | 0.751 | 0.410 | 1.377 | 0.372 | 0.729 | 0.392 | 1.356 | 0.335 | 0.871 | 0.464 | 1.631 | 0.685 | 0.864 | 0.455 | 1.640 | 0.872 |
Autumn | 0.844 | 0.478 | 1.490 | 0.582 | 0.829 | 0.461 | 1.488 | 0.551 | 0.997 | 0.556 | 1.785 | 0.961 | 1.060 | 0.581 | 1.931 | 0.805 |
Winter | 1.522 | 0.887 | 2.612 | 0.114 | 1.647 | 0.954 | 2.843 | 0.065 | 1.815 | 1.031 | 3.194 | 0.035 | 1.916 | 1.082 | 3.391 | 0.023 |
Location | Had collinearity with urbanization level | Had collinearity with urbanization level | ||||||||||||||
Northern Taiwan | Reference | Had collinearity with urbanization level | Reference | Had collinearity with urbanization level | ||||||||||||
Middle Taiwan | 1.391 | 0.861 | 2.245 | 0.159 | Had collinearity with urbanization level | 1.321 | 0.815 | 2.143 | 0.233 | Had collinearity with urbanization level | ||||||
Southern Taiwan | 1.025 | 0.603 | 1.740 | 0.878 | Had collinearity with urbanization level | 1.088 | 0.645 | 1.836 | 0.706 | Had collinearity with urbanization level | ||||||
Eastern Taiwan | 2.025 | 1.025 | 3.998 | 0.038 | Had collinearity with urbanization level | 1.632 | 0.806 | 3.304 | 0.160 | Had collinearity with urbanization level | ||||||
Outlets islands | 0.000 | - | - | 0.947 | Had collinearity with urbanization level | 0.000 | - | - | 0.944 | Had collinearity with urbanization level | ||||||
Urbanization level | ||||||||||||||||
1 (The highest) | 0.494 | 0.266 | 0.922 | 0.030 | 0.569 | 0.276 | 1.132 | 0.114 | 0.471 | 0.252 | 0.882 | 0.021 | 0.543 | 0.270 | 1.087 | 0.090 |
2 | 0.949 | 0.551 | 1.632 | 0.874 | 0.863 | 0.476 | 1.565 | 0.649 | 0.926 | 0.539 | 1.592 | 0.806 | 0.901 | 0.497 | 1.634 | 0.755 |
3 | 0.361 | 0.121 | 1.075 | 0.070 | 0.388 | 0.129 | 1.159 | 0.093 | 0.261 | 0.076 | 0.888 | 0.033 | 0.295 | 0.086 | 1.014 | 0.054 |
4 (The lowest) | Reference | Reference | Reference | Reference | ||||||||||||
Level of care | ||||||||||||||||
Hospital center | 1.582 | 0.866 | 2.891 | 0.123 | 1.663 | 0.860 | 3.218 | 0.119 | 1.377 | 0.764 | 2.481 | 0.265 | 1.569 | 0.822 | 2.996 | 0.157 |
Regional hospital | 1.840 | 1.033 | 3.278 | 0.034 | 1.494 | 0.817 | 2.735 | 0.176 | 1.412 | 0.801 | 2.487 | 0.212 | 1.326 | 0.731 | 2.404 | 0.327 |
Local hospital | Reference | Reference | Reference | Reference |
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Lee, Y.-L.; Tien, Y.; Bai, Y.-S.; Lin, C.-K.; Yin, C.-S.; Chung, C.-H.; Sun, C.-A.; Huang, S.-H.; Huang, Y.-C.; Chien, W.-C.; et al. Association of Postpartum Depression with Maternal Suicide: A Nationwide Population-Based Study. Int. J. Environ. Res. Public Health 2022, 19, 5118. https://doi.org/10.3390/ijerph19095118
Lee Y-L, Tien Y, Bai Y-S, Lin C-K, Yin C-S, Chung C-H, Sun C-A, Huang S-H, Huang Y-C, Chien W-C, et al. Association of Postpartum Depression with Maternal Suicide: A Nationwide Population-Based Study. International Journal of Environmental Research and Public Health. 2022; 19(9):5118. https://doi.org/10.3390/ijerph19095118
Chicago/Turabian StyleLee, Yi-Liang, Yun Tien, Yin-Shiuan Bai, Chi-Kang Lin, Chang-Sheng Yin, Chi-Hsiang Chung, Chien-An Sun, Shi-Hao Huang, Yao-Ching Huang, Wu-Chien Chien, and et al. 2022. "Association of Postpartum Depression with Maternal Suicide: A Nationwide Population-Based Study" International Journal of Environmental Research and Public Health 19, no. 9: 5118. https://doi.org/10.3390/ijerph19095118