{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T11:32:09Z","timestamp":1791545529176,"version":"4.3.4"},"reference-count":46,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2021,7,13]],"date-time":"2021-07-13T00:00:00Z","timestamp":1626134400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Natural Science Foundation of China youth project","award":["(grant no. 81703234)"],"award-info":[{"award-number":["(grant no. 81703234)"]}]},{"name":"the Medical Science and Technology Research Fund project of Guangdong Province","award":["(grant no. A2018335)"],"award-info":[{"award-number":["(grant no. A2018335)"]}]},{"name":"the Basic Research Free Exploration Project of Shenzhen City","award":["(grant no.JCYJ20180305163459491)"],"award-info":[{"award-number":["(grant no.JCYJ20180305163459491)"]}]},{"name":"the General Program of Stable Support Plan for Universities in Shenzhen City","award":["(grant no. 20200804101756002)"],"award-info":[{"award-number":["(grant no. 20200804101756002)"]}]},{"name":"the National Natural Science Foundation of China youth project","award":["(grant no. 81903412)"],"award-info":[{"award-number":["(grant no. 81903412)"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Background: Postpartum depression (PPD) has been recognized as a severe public health problem worldwide due to its high incidence and the detrimental consequences not only for the mother but for the infant and the family. However, the pattern of natural transition trajectories of PPD has rarely been explored. Methods: In this research, a quantitative longitudinal study was conducted to explore the PPD progression process, providing information on the transition probability, hazard ratio, and the mean sojourn time in the three postnatal mental states, namely normal state, mild PPD, and severe PPD. The multi-state Markov model was built based on 912 depression status assessments in 304 Chinese primiparous women over multiple time points of six weeks postpartum, three months postpartum, and six months postpartum. Results: Among the 608 PPD status transitions from one visit to the next visit, 6.2% (38\/608) showed deterioration of mental status from the level at the previous visit; while 40.0% (243\/608) showed improvement at the next visit. A subject in normal state who does transition then has a probability of 49.8% of worsening to mild PPD, and 50.2% to severe PPD. A subject with mild PPD who does transition has a 20.0% chance of worsening to severe PPD. A subject with severe PPD is more likely to improve to mild PPD than developing to the normal state. On average, the sojourn time in the normal state, mild PPD, and severe PPD was 64.12, 6.29, and 9.37 weeks, respectively. Women in normal state had 6.0%, 8.5%, 8.7%, and 8.8% chances of progress to severe PPD within three months, nine months, one year, and three years, respectively. Increased all kinds of supports were associated with decreased risk of deterioration from normal state to severe PPD (hazard ratio, HR: 0.42\u20130.65); and increased informational supports, evaluation of support, and maternal age were associated with alleviation from severe PPD to normal state (HR: 1.46\u20132.27). Conclusions: The PPD state transition probabilities caused more attention and awareness about the regular PPD screening for postnatal women and the timely intervention for women with mild or severe PPD. The preventive actions on PPD should be conducted at the early stages, and three yearly; at least one yearly screening is strongly recommended. Emotional support, material support, informational support, and evaluation of support had significant positive associations with the prevention of PPD progression transitions. The derived transition probabilities and sojourn time can serve as an importance reference for health professionals to make proactive plans and target interventions for PPD.<\/jats:p>","DOI":"10.3390\/ijerph18147449","type":"journal-article","created":{"date-parts":[[2021,7,13]],"date-time":"2021-07-13T04:26:06Z","timestamp":1626150366000},"page":"7449","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["States Transitions Inference of Postpartum Depression Based on Multi-State Markov Model"],"prefix":"10.3390","volume":"18","author":[{"given":"Juan","family":"Xiong","sequence":"first","affiliation":[{"name":"Health Science Center, Shenzhen University, Shenzhen 518060, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiyu","family":"Fang","sequence":"additional","affiliation":[{"name":"Health Science Center, Shenzhen University, Shenzhen 518060, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jialing","family":"Chen","sequence":"additional","affiliation":[{"name":"Health Science Center, Shenzhen University, Shenzhen 518060, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yingxin","family":"Li","sequence":"additional","affiliation":[{"name":"Health Science Center, Shenzhen University, Shenzhen 518060, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huiyi","family":"Li","sequence":"additional","affiliation":[{"name":"Health Science Center, Shenzhen University, Shenzhen 518060, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wenjie","family":"Li","sequence":"additional","affiliation":[{"name":"Health Science Center, Shenzhen University, Shenzhen 518060, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xujuan","family":"Zheng","sequence":"additional","affiliation":[{"name":"Health Science Center, Shenzhen University, Shenzhen 518060, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,7,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1192\/bjp.163.1.27","article-title":"A Controlled Study of the Onset, Duration and Prevalence of Postnatal Depression","volume":"163","author":"Cox","year":"1993","journal-title":"Br. J. Psychiatry"},{"key":"ref_2","first-page":"1407","article-title":"Postnatal depression","volume":"1","author":"Craig","year":"2009","journal-title":"Clin. Evid."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Radzi, W.M., Jenatabadi, H.S., and Samsudin, N. (2021). Postpartum depression symptoms in survey-based research: A structural equation analysis. BMC Public Health, 21.","DOI":"10.1186\/s12889-020-09999-2"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1016\/j.archger.2018.04.011","article-title":"Depression and its associated factors among elderly: A community-based study in Egypt","volume":"77","author":"Elkhawaga","year":"2018","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Zeng, N., Pope, Z., Lee, J., and Gao, Z. (2018). Virtual reality exercise for anxiety and depression: A preliminary review of current re-search in an emerging field. J. Clin. Med., 7.","DOI":"10.3390\/jcm7030042"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1093\/fampra\/cmn101","article-title":"The effectiveness of exercise in the management of post-natal depression: Systematic re-view and meta-analysis","volume":"26","author":"Daley","year":"2009","journal-title":"Fam. Prac."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1016\/j.ejogrb.2020.11.025","article-title":"Prevalence of postpartum depression at the clinic for obstetrics and gynecology in Kosovo teaching hospital: Demographic, obstetric and psychosocial risk factors","volume":"256","author":"Zejnullahu","year":"2021","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1590\/0101-60830000000242","article-title":"Prevalence and associated risk factors of postpartum depression: A cross sectional study","volume":"47","author":"Goweda","year":"2020","journal-title":"Arch. Clin. Psychiatry"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1016\/j.midw.2018.04.005","article-title":"Changes in maternal self-efficacy, postnatal depression symptoms and social support among Chinese primiparous women during the initial postpartum period: A longitudinal study","volume":"62","author":"Zheng","year":"2018","journal-title":"Midwifery"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1097\/01.AOG.0000183597.31630.db","article-title":"Perinatal depression a systematic review of prevalence and incidence","volume":"106","author":"Gavin","year":"2005","journal-title":"Obstet. Gynecol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12884-020-03092-7","article-title":"Postnatal depression and its association with adverse infant health outcomes in low- and middle-income countries: A systematic review and meta-analysis","volume":"20","author":"Dadi","year":"2020","journal-title":"BMC Pregnancy Childbirth"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Chew-Graham, C., Sharp, D., Chamberlain, E., Folkes, L., and Turner, K.M. (2009). Disclosure of symptoms of postnatal depression, the perspectives of health professionals and women: A qualitative study. BMC Fam. Prac., 10.","DOI":"10.1186\/1471-2296-10-7"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"s10","DOI":"10.1192\/bjp.184.46.s10","article-title":"Postnatal depression across countries and cultures: A qualitative study","volume":"184","author":"Oates","year":"2004","journal-title":"Br. J. Psychiatry"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Pe\u00f1acoba Puente, C., Suso-Ribera, C., Blanco Rico, S., Mar\u00edn, D., San Rom\u00e1n Montero, J., and Catal\u00e1, P. (2021). Is the association between postpartum depression and early maternal\u2013infant relationships contextually determined by avoidant coping in the Mother?. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18020562"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.midw.2017.12.022","article-title":"A quantitative longitudinal study to explore factors which influence maternal self-efficacy among Chinese primiparous women during the initial postpartum period","volume":"59","author":"Zheng","year":"2018","journal-title":"Midwifery"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Wang, Q., Zhang, Y., Li, X.L., Ye, Z.W., Huang, L.L., Zhang, Y., and Zheng, X.J. (2021). Exploring maternal self-efficacy of first-time mothers among rural-to-urban floating women: A quantitative longitudinal study in China. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18062793"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12884-020-03535-1","article-title":"Effect of postpartum depression on exclusive breast-feeding practices in sub-Saharan Africa countries: A systematic review and meta-analysis","volume":"21","author":"Woldeyohannes","year":"2021","journal-title":"BMC Pregnancy Childbirth"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1016\/j.jad.2007.09.013","article-title":"Impact of postnatal depression on infants\u2019 growth in Nigeria","volume":"108","author":"Adewuya","year":"2008","journal-title":"J. Affect. Disord."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1111\/j.1651-2227.2007.00184.x","article-title":"Does maternal postpartum depressive symptomatology influence infant feeding outcomes?","volume":"96","author":"Dennis","year":"2007","journal-title":"Acta Paediatr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1080\/02646831003587353","article-title":"Attachment and interpersonal relationships in postnatal depression","volume":"28","author":"Wilkinson","year":"2010","journal-title":"J. Reprod. Infant Psychol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"110295","DOI":"10.1016\/j.jpsychores.2020.110295","article-title":"Risk factors for postpartum depression in Chinese women: A cross-sectional study at 6 weeks postpartum","volume":"140","author":"Shi","year":"2021","journal-title":"J. Psychosom. Res."},{"key":"ref_22","first-page":"154","article-title":"Postpartum depression: Risks and early detection","volume":"118","year":"2020","journal-title":"Arch. Argent. Pediatr."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1016\/S0010-440X(03)00034-8","article-title":"Endocrine factors in the etiology of postpartum depression","volume":"44","author":"Bloch","year":"2003","journal-title":"Compr. Psychiatry"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"766","DOI":"10.1016\/j.pnpbp.2009.09.006","article-title":"Depression during pregnancy and postpartum: Contribution of stress and ovarian hormones","volume":"34","author":"Brummelte","year":"2010","journal-title":"Prog. Neuro-Psychopharmacol. Biol. Psychiatry"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1177\/1099800410362112","article-title":"The heritability of postpartum depression","volume":"12","author":"Corwin","year":"2010","journal-title":"Biol. Res. Nurs."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1016\/j.genhosppsych.2004.02.006","article-title":"Antenatal risk factors for postpartum depression: A synthesis of recent literature","volume":"26","author":"Robertson","year":"2004","journal-title":"Gen. Hosp. Psychiatry"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1146\/annurev-clinpsy-101414-020426","article-title":"Biological and psychosocial predictors of postpartum depression: Systematic review and call for integration","volume":"11","author":"Yim","year":"2015","journal-title":"Annu. Rev. Clin. Psychol."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Mart\u00ednez-Borba, V., Suso-Ribera, C., Osma, J., and Andreu-Pej\u00f3, L. (2020). Predicting Postpartum Depressive Symptoms from Pregnancy Biopsychosocial Factors: A Longitudinal Investigation Using Structural Equation Modeling. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17228445"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1109\/JBHI.2020.3006217","article-title":"Blood Pressure States Transition Inference Based on MultiState Markov Model","volume":"25","author":"Yang","year":"2021","journal-title":"IEEE J. Biomed. Health Inform."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1111\/1753-0407.12384","article-title":"Projection of prediabetes and diabetes population size in singapore using a dynamicmarkovmodel","volume":"9","author":"Wong","year":"2017","journal-title":"J. Diabetes"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1","DOI":"10.5336\/biostatic.2018-62156","article-title":"A multi-state markov model for the progression of chronic kidney disease","volume":"11","author":"Grover","year":"2019","journal-title":"T\u00fcrkiye Klin. Biyoistatistik"},{"key":"ref_32","first-page":"132","article-title":"Using Markov Chains to predict the natural progression of diabetic retinopathy","volume":"8","author":"Srikanth","year":"2015","journal-title":"Int. J. Ophthalmol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"782","DOI":"10.1192\/bjp.150.6.782","article-title":"Detection of postnatal depression: Development of the 10-Item Edinburgh Postnatal Depression Scale","volume":"150","author":"Cox","year":"1987","journal-title":"Br. J. Psychiatry"},{"key":"ref_34","unstructured":"Cox, J., and Holden, J. (2003). Perinatal Mental Health: A Guide to the Edinburgh Postnatal Depression Scale (EPDS), Gaskell."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"813","DOI":"10.1016\/j.ijnurstu.2009.01.010","article-title":"Psychometric evaluation of the Mainland Chinese version of the Edinburgh Postnatal Depression Scale","volume":"46","author":"Wang","year":"2009","journal-title":"Int. J. Nurs. Stud."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"m4022","DOI":"10.1136\/bmj.m4022","article-title":"Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: Systematic review and meta-analysis of indi-vidual participant data","volume":"371","author":"Levis","year":"2020","journal-title":"BMJ"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1001\/jama.2015.18948","article-title":"Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the US Preventive Services Task Force","volume":"315","author":"Rossom","year":"2016","journal-title":"JAMA"},{"key":"ref_38","first-page":"731","article-title":"The relationship between social support and postnatal depression of primiparous women","volume":"36","author":"Lu","year":"2001","journal-title":"Chin. J. Nurs."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3310\/hta13360","article-title":"Methods to identify postnatal depression in primary care: An integrated evidence synthesis and value of information analysis","volume":"13","author":"Hewitt","year":"2009","journal-title":"Health Technol. Assess."},{"key":"ref_40","unstructured":"National Collaborating Centre for Mental Health (2014). Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance, British Psychological Society. [Updated ed.]."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"784","DOI":"10.7326\/0003-4819-151-11-200912010-00006","article-title":"Screening for Depression in Adults: U.S. Preventive Services Task Force Recommendation Statement","volume":"151","author":"Force","year":"2009","journal-title":"Ann. Intern. Med."},{"key":"ref_42","unstructured":"Austin, M.-P., and Highet, N. (2013). Guidelines Expert Advisory Committee. Clinical Practice Guidelines for Depression and Related DisOrders\u2014Anxiety, Bipolar Disorder and Puerperal Psychosis\u2014In the Perinatal Period. A Guideline for Primary Care Health Professionals, Beyondblue. The National Depression Initiative."},{"key":"ref_43","unstructured":"National Institute of Child Health and Human Development (NICHD) (2020). Postpartum depression may persist three years after giving birth. JAMA, 324, 2475."},{"key":"ref_44","unstructured":"General Office of the National Health Commission (2021, March 03). Notice of the General Office of the NationalHealth Commission on Exploring the Implementation of Special Services for the Prevention and Treatment of Depression and Senile Dementia, Available online: http:\/\/www.nhc.gov.cn\/jkj\/s7914\/202009\/a63d8f82eb53451f97217bef0962b98f.shtml."},{"key":"ref_45","unstructured":"Zheng, X.J., Morrell, J., and Watts, K. (2015). An Exploration of Factors which Influence Maternal Self-Efficacy in Primiparous Women in China during the Initial Postnatal Period. [Ph.D. Thesis, The University of Nottingham]."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Gong, W., Jin, X., Cheng, K., Caine, E., Lehman, R., and Xu, D. (2020). Chinese women\u2019s acceptance and uptake of referral after screening for perinatal depression. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17228686"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/14\/7449\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:29:36Z","timestamp":1760164176000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/14\/7449"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,13]]},"references-count":46,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2021,7]]}},"alternative-id":["ijerph18147449"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18147449","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7,13]]}}}