Yang N, Chen YH, Li LX, Lai XL. Status and influencing factors of anxiety and depression in pregnant women with hypertensive disorders of pregnancy. World J Psychiatry 2026; 16(7): 117399 [DOI: 10.5498/wjp.117399]
Corresponding Author of This Article
Xiao-Lu Lai, Department of Obstetrics, The Second Affiliated Hospital, Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou 362000, Fujian Province, China. xiaolulai0923@163.com
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Psychiatry
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Yang N, Chen YH, Li LX, Lai XL. Status and influencing factors of anxiety and depression in pregnant women with hypertensive disorders of pregnancy. World J Psychiatry 2026; 16(7): 117399 [DOI: 10.5498/wjp.117399]
Ning Yang, Ya-Hong Chen, Xiao-Lu Lai, Department of Obstetrics, The Second Affiliated Hospital, Fujian Medical University, Quanzhou 362000, Fujian Province, China
Li-Xia Li, Department of Psychiatry, The Third Hospital of Quanzhou, Quanzhou 362000, Fujian Province, China
Author contributions: Yang N and Chen YH contributed to the study’s conceptualization, methodology, data analysis, and original draft writing, and they contributed equally to this manuscript and are co-first authors; Li LX was responsible for data curation; Lai XL contributed to the study’s conceptualization, methodology, supervision, review, editing, and funding acquisition. All the authors have reviewed and approved the final manuscript.
Institutional review board statement: This study was reviewed and approved by the Institutional Review Board of the Second Affiliated Hospital of Fujian Medical University, No. 2025-606.
Informed consent statement: All study participants or their legal guardians provided written informed consent before study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: Data supporting the findings of this study are available from the corresponding author upon request.
Corresponding author: Xiao-Lu Lai, Department of Obstetrics, The Second Affiliated Hospital, Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou 362000, Fujian Province, China. xiaolulai0923@163.com
Received: January 23, 2026 Revised: March 4, 2026 Accepted: April 7, 2026 Published online: July 19, 2026 Processing time: 158 Days and 3.4 Hours
Abstract
BACKGROUND
While hypertensive disorders of pregnancy (HDP) are well-known for physical risks, their psychological impact, particularly regarding anxiety and depression, remains inadequately examined. The concurrent physiological stress and illness-related concerns likely elevate mental health risks. This study hypothesized that lower education levels, postpartum mother–infant separation, insufficient family support, and sleep disorders are significant risk factors for anxiety and depression in women with HDP.
AIM
To identify the risk factors of anxiety and depression among patients with HDP to guide clinical interventions.
METHODS
Notably, 548 pregnant women with HDP were selected as participants among inpatients between March 2023 and March 2025. The patients were divided into symptomatic and asymptomatic groups. The Self-Rating Anxiety Scale and Self-Rating Depression Scale were used to assess anxiety and depression levels, respectively, in all patients.
RESULTS
After analyzing 531 valid questionnaires among women with HDP, the prevalence of anxiety and depression was found to be 41.91% (215/531). Significant differences were observed between the case and control groups in terms of education level, postpartum mother–infant separation, family support, and sleep disorders (P < 0.05). Logistic regression analysis confirmed that the four factors were independent risk factors (odds ratio > 1, P < 0.05). Anxiety and depression scores were negatively correlated with education level and family support and positively correlated with mother–infant separation and sleep disorders (P < 0.05).
CONCLUSION
Increased anxiety and depression among mothers with HDP are correlated with lower education levels, postpartum separation, inadequate family support, and sleep disorders.
Core Tip: The prevalence of anxiety and depressive symptoms in patients with hypertensive disorders of pregnancy was relatively high (41.91%). This study identified low education levels, postpartum separation of the mother and child, insufficient family support, and sleep disorders as significant risk factors. The decision tree demonstrating the degree of family care as the root node had good predictive performance (area under the curve = 0.826). This model provides an effective tool for the early identification of individuals with hypertensive disorders of pregnancy at high risk of anxiety and depression.
Citation: Yang N, Chen YH, Li LX, Lai XL. Status and influencing factors of anxiety and depression in pregnant women with hypertensive disorders of pregnancy. World J Psychiatry 2026; 16(7): 117399
Hypertension during pregnancy is known as gestational hypertensive disorders of pregnancy (HDP). This can increase morbidity and mortality rates in mothers and infants during the perinatal period[1]. Notably, HDP can impair placental function, leading to reduced placental perfusion and acute atherosclerosis of the placental vessels. The risks of adverse pregnancies include an increased risk of fetal growth restriction, premature birth, and fetal distress[2]. Notably, HDP pathogenesis is complex. Insufficient uterine spiral artery remodeling is a perspective agreed upon by most researchers. The dysfunction of endothelial cells throughout the body is caused by the abnormal development of placental blood vessels and insufficient placental perfusion. Furthermore, HDP is associated with dopamine-induced edema, oxidative stress symptoms, two types of hypertension, and preeclampsia[3,4]. Other studies have indicated that mood disorders can become more severe. Anxiety and depression, associated with endothelial dysfunction, can have an impact on blood pressure variability[5,6].
Physiological changes during pregnancy, the transformation of social roles, and the adjustment of emotional needs are the three main factors affecting the mental health of pregnant women. Data has shown that approximately 10% of pregnant women have mental-health problems. This percentage reaches 13% in postpartum women. Pregnant women with gestational HDP should bear additional concerns regarding the disease and the safety of the mother and baby. This dual pressure on the body and mind exacerbates emotional disorders[7].
Studies have shown that postpartum depression can impair a mother’s cognitive function and affect her physical recovery. The frequency of interactions between mothers and babies decreases accordingly, whereas the quality of interactions decreases significantly. These changes have long-term adverse effects on neural development in infants[8]. In a study conducted in Western Australia that followed up 1389 children until the age of 10 years, babies of mothers with HDP generally had weaker language abilities and a significantly increased risk of language development[9]. Existing research has confirmed that the emotional state of women with pregnancy complications is influenced by the number of deliveries and monthly family income[10]. This study systematically reviewed 548 inpatient cases of HDP in a hospital from March 2023 to 2025 to identify the factors influencing anxiety and depression, provide empirical evidence for clinical intervention, and help alleviate emotional distress in parturients.
MATERIALS AND METHODS
Study design and patients
According to the prospective sample size calculation formula: N = [Z²α/2 × P(1-P)]/δ2, taking α = 0.05, Z²α/2 = 1.96, the overall ratio P and allowable error δ were 0.47 and 0.07, respectively, and at least 195 samples were required. A total of 548 parturients with HDP admitted to the hospital between March 2023 and 2025 were selected as participants. Therefore, the initial criteria were satisfied. After excluding those with missing data on confounders, 531 parturients with HDP were included in the final analysis, with an effective recovery rate of 96.90% (531/548) (Figure 1).
Figure 1 Technical roadmap.
HDP: Hypertensive disorders of pregnancy.
Inclusion criteria: (1) Met the diagnostic criteria for HDP[11]; (2) First episode; Singleton pregnancy, and (3) Age ≥ 18 years. The participants understood the study protocol and provided written informed consent.
Exclusion criteria: (1) Comorbid malignant tumors; (2) History of mental disorders or the inability to communicate effectively; (3) Presence of other obstetric complications; Preexisting diagnosis of anxiety or depression prior to pregnancy; (4) Previous diagnosis of infertility; and (5) History of hospitalization during pregnancy. This study was reviewed and approved by the Institutional Review Board of The Second Affiliated Hospital, Fujian Medical University.
Measures
Design baseline data form: The form was completed by thoroughly reviewing patient information, such as age and educational background, through the hospital’s electronic medical record system. Maternal anxiety was assessed using the Self-Rating Anxiety Scale (SAS)[12], a 20-item instrument developed by Zung in 1971 with demonstrated reliability (Cronbach’s α = 0.855). Each item used a one to four scoring system, with the raw total score converted to a standardized metric (maximum 100 points) through multiplication by 1.25, with higher scores indicating higher anxiety severity. Similarly, depression was evaluated using Zung’s Self-Rating Depression Scale (SDS)[13] from 1965 (Cronbach’s α = 0.841), using identical scoring methodology and interpretation guidelines. Participants who met the threshold of SDS standardized scores ≥ 53 or SAS standardized scores ≥ 50 were classified as the with anxiety/depression group, whereas the remaining participants constituted the without anxiety/depression group.
Family support assessment was conducted using the Family Adaptation Partnership Growth Affection Resolve[14] questionnaire developed by Smilkstein in 1978 (Cronbach’s α = 0.819), which evaluates the following functional aspects: Adaptation, partnership, growth, affection, and resolve. Each aspect was rated from zero to two points, generating a total score range of 0 to 10, with higher scores reflecting adequate family functioning. The presence of sleep disorders was evaluated using the Pittsburgh Sleep Quality Index[15]. This scale was developed by Buysse in 1989, with a Cronbach’s α value of 0.830. It covers seven aspects, including subjective sleep quality and sleep duration, with 23 items; the total score ranges from 0 to 21[15]. The scores were negatively correlated with sleep quality. A Pittsburgh Sleep Quality Index score of seven or above indicates the presence of sleep disorders, whereas a score below seven indicates no sleep disorders. Comprehensive baseline data were collected using a structured questionnaire documenting key variables, such as maternal age, gravidity, parity, place of residence, education level, employment status, regular prenatal checkups, fetal sex, gestational age at delivery, delivery mode, and postpartum mother-infant separation. If the mother and infant were physically separated for a period equal to or greater than 24 hours within the first seven days postpartum, it denoted postpartum mother-infant separation.
Quality control
All questionnaires were completed through an in-person patient evaluation. Prior to the survey, the patients were informed of the purpose of the questionnaire and instructions for its completion. The study was completed only after obtaining patient consent. After completion, the questionnaires were promptly reviewed to ensure the survey quality. Surveys exhibiting obvious patterns in responses or with more than one-third of the questions left blank were deemed invalid and excluded from the statistical analysis.
Statistical analysis
Data analysis was performed using SPSS 27.0. The normality of continuous variables was tested using the Shapiro-Wilk test. The age and number of pregnancies conforming to the normal distribution were expressed as mean ± SD, whereas the differences between groups were evaluated by an independent samples t-test. Categorical data were described as percentages and analyzed using χ2 tests. Multi-class variable analysis was corrected using Bonferroni, and the adjusted significance level was set to the original α value (0.05) divided by the number of comparisons. Correlations between the variables were tested using Pearson’s and Spearman’s correlation analyses. The factors influencing anxiety and depression in patients with HDP were explored using a logistic regression model. Simultaneously, this study established a decision-tree model to predict the risk of anxiety and depression in patients with HDP.
RESULTS
Survey response rate
Notably, 548 questionnaires were distributed, and 531 valid questionnaires were retrieved, with an effective recovery rate of 96.90% (531/548) (Figure 1).
Status of anxiety and depression in parturients with HDP
Among 531 parturients with HDP, the average SAS and SDS scores were 46.35 ± 4.12 and 44.20 ± 3.81, respectively. Among them, 215 (40.49%) reported symptoms of anxiety or depression.
Comparison of baseline characteristics
Intergroup comparisons revealed significant differences in education level, postpartum mother-infant separation, family support level, and sleep disorders (P < 0.05), whereas no statistically significant differences were observed in other baseline characteristics (Table 1).
Table 1 Comparison of baseline data between the with anxiety/depression group and the without anxiety/depression group, mean ± SD/n (%).
Logistic regression analysis of factors influencing anxiety and depression in parturients with HDP
Univariate logistic regression analysis included variables with significant differences in baseline characteristics. Indicators with a P-value < 0.2 were further included in the multivariate regression model. The variable assignments are presented in Table 2. The analysis showed that low education level, low family support, postpartum separation of the mother and infant, and sleep disorders are risk factors for anxiety and depression in mothers with HDP (odds ratio > 1, P < 0.05) (Table 3 and Figure 2).
Figure 2 Forest plot of the relationship between major indicators and anxiety and depression in pregnant women with hypertensive disorders of pregnancy.
OR: Odds ratio.
The Logistic regression results were used as predictor variables in the decision tree model (Figure 3). The model structure consisted of four layers and 13 nodes. The degree of family support was an important root node variable in the decision tree.
Figure 3 Decision tree model for anxiety and depression in pregnant women with hypertensive disorders of pregnancy.
Adj P-value: Adjusted P-value.
Predictive performance of the decision tree model
The area under the curve of the decision-tree model was 0.826 (95% confidence interval: 0.791-0.860), with a sensitivity, specificity, and Youden’s index of 0.814, 0.674, and 0.488, respectively. The receiver operating characteristic curves are shown in Figure 4.
Figure 4 Receiver operating characteristic plot of the decision tree model for anxiety and depression in parturients with hypertensive disorders of pregnancy.
ROC: Receiver operating characteristic.
Correlation between various indicators and anxiety/depression in parturients with HDP
The correlation analysis results (Table 4) indicated that the SAS and SDS scores are strongly and negatively correlated with education and family supportand positively correlated with postpartum mother-infant separation and sleep disorders (P < 0.05).
Table 4 Correlation between various indicators and anxiety and depression in pregnant women with hypertensive disorders of pregnancy (r/P).
This retrospective analysis showed that 40.49% of patients with HDP had anxiety or depression, revealing the mental health burden on this group. This result corroborates previous findings[16]. Notably, 215 out of 531 parturients with HDP (440.49%) had anxiety or depression. This study identified multiple significant factors related to anxiety and depression through logistic regression analysis. Low educational levels, insufficient family support, postpartum separation of the mother and infant, and sleep disorders are risk factors for anxiety. Correlation analysis showed that the SAS and SDS scores are negatively correlated with education level and the degree of family support, and positively correlated with postpartum mother-infant separation and sleep disorders. A cohort study that included 1349 pregnant women in Finland found that compared with higher education, primary education could increase the Generalized Anxiety Disorder-7 by 2.4 points, equivalent to an increase of 0.6 standard deviations[17]. This result confirms that a lower level of education significantly aggravates prenatal anxiety symptoms and suggests that it has a significant negative impact on the mental health of pregnant women with HDP. Parturients with a lower level of education generally experience hindrances in obtaining health information, which directly leads to an insufficient awareness of their condition. Limitations in information acquisition can significantly affect patients’ understanding of disease mechanisms and treatment plans, while undermining their ability to process professional medical information, thereby reducing their willingness to take appropriate clinical response measures. Long-standing concerns regarding the safety of mothers and infants are more likely to lead to clinically significant anxiety and depression symptoms in the context of scarce cognitive resources[18]. Highly educated pregnant women with HDP should capitalize on the diverse channels in the information context to systematically master disease knowledge. They should actively cooperate with medical interventions, scientifically identify postpartum emotional fluctuations, and promptly take regulatory measures to significantly reduce the risk of anxiety and depression[19].
It is recommended that in-person health education should be provided to low-educated pregnant women with HDP. Visual aids (defined as educational materials presented in visual format, including anatomical diagrams, instructional videos, and illustrated brochures) should be used to convey intuitive evidence-based medical knowledge. Combined with cognitive behavioral therapy, it helps patients identify and correct irrational beliefs. Comprehensive interventions can effectively reduce the incidence of anxiety and depression in this population. Postpartum mother-infant separation is an important psychological concern that can overactivate the hypothalamic-pituitary-adrenal axis and cause an abnormal elevation of cortisol levels. Pregnant women with HDP exhibit hypothalamic-pituitary-adrenal axis dysfunction. Postpartum separation further aggravates the neuroendocrine imbalance and damages the negative feedback mechanism. High cortisol levels damage hippocampal neurons and eventually disrupt emotional regulation in the long-term[20,21].
Mothers with HDP are often guilty and blame themselves because of their illness and the experience of being separated from their babies. Concerns regarding their infant’s health, along with insufficient disease awareness, can easily lead to a negative assessment of the condition. Psychological stress eventually manifests as severe symptoms of anxiety and depression[22,23]. Negative emotions can lower serum prolactin levels in parturients with HDP, leading to decreased milk production. These physiological changes further aggravate emotional disorders, thereby creating a vicious cycle that leads to the persistence of psychological problems[24,25]. It is recommended that a systematic breastfeeding plan be formulated for parturients with HDP experiencing separation from their infant. Regular stimulation with a breast pump should be initiated within 6 h of separation. Medical staff should guide family members to enhance emotional support, promptly inform infants of their health status, and effectively alleviate anxiety and depression in parturients.
Research has confirmed that pregnancy anxiety is negatively correlated with family support[26]. Notably, the decision tree model identified family support as the most important root node, indicating that it plays a crucial role in predicting anxiety and depression in patients with HDP. HDP is inherently accompanied by physiological stress, prolonged hospital stays, close monitoring, and concerns about the outcomes for both the mother and baby. Family support reflects the support and emotional attention among members, covering emotional bonds, behavioral patterns, and communication styles. These aspects collaborate to maintain and enhance self-esteem and promote mental health[27,28]. Patients with HDP and inadequate family support receive insufficient assistance and are more likely to experience helplessness and loneliness when experiencing stress. A lack of security after childbirth directly affects the psychological state and causes obvious symptoms of anxiety and depression[29,30]. Insufficient family support leads to a decrease in the care of parturients with HDP, weakened self-esteem and self-awareness, and a lack of sense of belonging and security. Considering maternal and infant health challenges, a lack of family support exacerbates emotional vulnerability and significantly increases the risk of anxiety and depression[31,32]. In this context, focusing on family support is of crucial importance. Full support from family members can buffer patients' negative emotions. Emotional comfort can alleviate feelings of helplessness and isolation. Furthermore, practical assistance in daily activities, childcare, and other aspects can enhance patients' sense of control. From an intervention perspective, family-centered care models should be given due attention. Healthcare providers should assess family support in the early perinatal period and implement targeted interventions for patients with low family support, actively involving family members in the educational, decision-making, and psychological support processes.
Sleep disorders among mothers with HDP can increase their risk of anxiety and depression. Similar findings have been reported by Tariq et al[33]. Unlike primary insomnia, sleep disorders among mothers with HDP have distinct disease-specific characteristics. Sleep disorders can cause mothers with HDP to frequently experience fatigue and difficulty concentrating on daytime activities. Antihypertensive drugs can cause frequent nocturia, which directly disrupts sleep. The physical discomfort caused by the disease itself, such as severe edema and breathing difficulties, can interfere with falling asleep and maintaining sleep. The hospital environment, such as nocturnal vital sign monitoring, fetal heart rate checks, and medical equipment noise, can exacerbate sleep fragmentation. Furthermore, anxiety about blood pressure and fetal outcomes can exacerbate sleep disorders, and in turn, sleep disorders can further intensify anxiety. These factors not only directly undermine sleep continuity but also affect emotion regulation through neuroendocrine pathways, thus creating a vicious cycle. Disruption of the circadian rhythm, regulated by the suprachiasmatic nucleus of the hypothalamus, leads to an abnormal increase in melatonin and cortisol levels. This causes sleep disorders and weakens the ability to regulate emotions, thus resulting in anxiety and depression[34]. Moreover, mothers with HDP experience additional psychological stress due to concerns regarding the impact of diseases on the fetus, frequent medical monitoring, and possible hospitalization. Sleep disorders further weaken the ability of mothers with HDP to cope with stress, thereby increasing their risk of anxiety and depression[35]. Therefore, for this group, clinical intervention should simultaneously focus on sleep management and disease control. In this regard, it is recommended that the blood pressure of parturients with HDP (high-risk) should be monitored, and the use of sleep-disrupting medications should be avoided. Sleep hygiene education, such as regular sleep schedules, warm baths before bedtime, and listening to relaxing music, should be provided to parturients. Furthermore, parturients with similar experiences should share their experiences to enhance their coping abilities and reduce their risk of anxiety and depression.
The decision tree model revealed that the degree of family support is an important root variable and the most relevant influencing factor. Therefore, family support-related interventions should be implemented to reduce the risk of anxiety and depression among parturients with HDP. In this regard, we suggest the following strategies. First, it is vital to provide family-oriented education and encourage family members and patients to participate together in prenatal courses. Second, a family support screening mechanism should be established. Third, the creation of a family assistance network can offer coping strategies and emotional support to families undergoing similar experiences. Furthermore, interventions that strengthen the family system may yield greater benefits than those that focus solely on individuals.
CONCLUSION
In summary, women with HDP are at a higher risk of developing anxiety and depression, and the determinants of anxiety and depression may include education level, postpartum separation of the mother and baby, family support, and sleep disorders. Moreover, the occurrence of anxiety and depression among pregnant women with HDP can be effectively evaluated by establishing a decision-tree algorithm model. However, this study has several limitations, such as incomplete sample data collection and regional distribution differences. Future research must improve these aspects and conduct a more extensive analysis to provide a scientific basis for a clinical intervention plan for pregnant women with HDP. It is also vital to develop tools that predict anxiety and depression risk among patients with HDP.
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