the lifetime risk of depressive symptoms in women ( 5.921.3% ) is about twice that in men and symptoms often start in the childbearing years [ 13 ] . prevalence rates of 1025% during pregnancy [ 49 ] and of 616% post - partum are reported [ 5 , 6 , 8 , 1012 ] . most researchers found higher rates during pregnancy than after childbirth [ 5 , 6 , 8 ] . urogenital symptoms are also more prevalent in pregnancy than in the general population . prevalence rates of 950% have been reported for urinary incontinence ( ui ) during first pregnancy and 3495% for frequency and urgency symptoms ( over - active bladder [ oab ] syndrome ) [ 13 , 14 ] . strong associations are found between depressive symptoms , urinary incontinence and over - active bladder syndrome in non - pregnant women [ 1519 ] . whilst the relationship of depressive symptoms and urinary symptoms has not yet been explored in pregnancy , several factors have been found to be associated with depressive symptoms in a general , pregnant and post - partum population . these factors include biomedical factors such as obesity , age , chronic pain ( like back pain ) , previous depressive symptoms [ 12 , 20 , 21 ] , behavioural factors like excessive use of alcohol , smoking , lack of leisure time physical exercise and socioeconomic factors like unemployment and low job satisfaction [ 5 , 7 , 22 ] . psychosocial factors , such as poorer social support , stressful life events and personality features have also been found related to depressive symptoms [ 11 , 2225 ] . the aim of this study was to ( 1 ) analyse the prevalence of depressive symptoms and urinary symptoms during and after pregnancy and ( 2 ) assess the association of urinary symptoms with depressive symptoms , controlling for psychosocial , behavioural , socioeconomic and biomedical factors during and after pregnancy . between january 2002 and july 2003 , 1,366 nulliparous pregnant women from 10 urban midwifery practices in the center of the netherlands were approached to take part in a prospective longitudinal cohort study assessing pelvic floor problems , sexuality and back pain during first pregnancy until 1  year after delivery . after 1  week , the women were approached by phone and asked if they wanted to participate in the study . inclusion criteria were a singleton low risk pregnancy and sufficient knowledge of the dutch language . one hundred and twenty - two women were excluded due to having a twin pregnancy ( n  =  2 ) , miscarriage ( n  =  13 ) or insufficient knowledge of the dutch language ( 107 ) . the most common reasons for refusal were lack of time and the intensity and intrusiveness of the questions . all participants signed an informed consent form . to assess the prevalence rates at different points in time of depressive symptoms , stress urinary incontinence ( sui ) , urge urinary incontinence ( uui ) and over - active bladder ( oab ) syndrome , we used data obtained from all respondents of questionnaires sent at 12 and 36  weeks gestation and 3 and 12  months post - partum . in addition , we analysed data obtained from the questionnaires sent at 36  weeks gestation and 12  months after delivery to assess the possible association between urinary symptoms and depression . we did so because the prevalence of urinary symptoms peak in the third trimester and because pelvic floor symptoms , occurring in pregnancy and persisting 1  year after delivery , may be associated with depression at this time . depressive symptoms were investigated using the center for epidemiologic studies depression scale ( ces - d ) . this scale is developed for use in non - psychiatric populations and gives an impression of depressive symptoms [ 27 , 28 ] . the total score ranges from 0 to 60 ; a higher score corresponds with more depressive symptoms . a cut - off score of 16 is frequently used as an indication of a possible clinical depression . we refer in this study to women who scored b16 on the ces - d as having depressive symptoms . urinary symptoms were assessed with the urogenital distress inventory ( udi ) [ 29 , 30 ] . this questionnaire consists of 19 questions about urogenital symptoms and the experienced discomfort of these symptoms . we looked specifically at self - reported urge and stress urinary incontinence and over - active bladder syndrome . although the udi also consists of questions on prolapse , obstructive micturition and pain and heaviness in the pelvic area , these symptoms have not been linked to depression in current literature . urge incontinence was determined by a positive answer to the question :  do you experience urine leakage related to the feeling of urgency ? stress incontinence was determined by a positive answer to the question :  do you experience urine leakage related to physical activity , coughing or sneezing ?  over - active bladder syndrome was determined when both of the following questions were answered positively :  do you experience frequent urination ?  and  do you experience a strong feeling of urgency to empty your bladder ? validated questionnaires were used to assess potential confounding variables . the dutch personality questionnaire ( dpq ) contains 133 statements , which are divided into 7 domains : inadequacy , social inadequacy , rigidity , hostility , egoism , dominance and self - esteem . the higher the score , the more these characteristics are part of the subject s personality . personality traits are stable and this questionnaire was completed at 24  weeks gestation for logistic reasons . the maudsley marital questionnaire ( mmq ) was used to measure the subjective emotional and sexual relationship of the woman with her partner . the mmq consists of 15 questions , of which 10 concern emotional aspects ( range 080 ) and 5 concern sexual aspects ( range 040 ) of the relationship . the higher the score , the worse this specific aspect of the relationship is perceived . biomedical factors included length and weight at 36  weeks gestation and 1  year after delivery , age at time of delivery , the presence of a chronic illness or back pain and the use of medication . data on mode of delivery and pregnancy - related complications ( hypertensive disorders , premature delivery , growth retardation and vaginal blood loss ) were obtained from the case files of obstetricians and midwifes . data on length and weight were transformed into a body mass index ( bmi  =  weight/(height ) ) . socioeconomic factors consisted of level of education , marital state , employment and job satisfaction . for practical reasons , the education level was dichotomised into high school or less and more than high school . behavioural factors we studied were whether participants smoked , used alcohol or were involved in leisure time physical activity in early pregnancy . in addition changes in prevalence of depressive symptoms , uui , sui and oab between 6 and 12  weeks gestation and between 36  weeks gestation and 3 and 12  months after delivery was determined using the mcnemar tests . possible variables associated with depressive symptoms , including urinary symptoms , were analysed in women that responded to the questionnaire at 36  weeks gestation and 1  year after delivery . women with and without ces - d b16 were compared in univariate analyses using the independent samples t - test for continuous variables and chi - squared test for categorical variables . the relationship between depressive symptoms ( ces - d _ 16 ) ( dependent variable ) , urinary symptoms and potential confounders was assessed using multivariate logistic regression analysis ( stepwise forward method ) to assess whether urinary symptoms remained associated with depressive symptoms . only significantly associated variables in univariate analyses ( p  < odds ratios ( exp ( b ) ) for continuous variables were calculated when appropriate . the hosmer and lemeshow test was used to establish the goodness of fit of the model . a p value of > 0.05 indicates that the model provides a valid representation of data . between january 2002 and july 2003 , 1,366 nulliparous pregnant women from 10 urban midwifery practices in the center of the netherlands were approached to take part in a prospective longitudinal cohort study assessing pelvic floor problems , sexuality and back pain during first pregnancy until 1  year after delivery . after 1  week , the women were approached by phone and asked if they wanted to participate in the study . inclusion criteria were a singleton low risk pregnancy and sufficient knowledge of the dutch language . one hundred and twenty - two women were excluded due to having a twin pregnancy ( n  =  2 ) , miscarriage ( n  =  13 ) or insufficient knowledge of the dutch language ( 107 ) . the most common reasons for refusal were lack of time and the intensity and intrusiveness of the questions . to assess the prevalence rates at different points in time of depressive symptoms , stress urinary incontinence ( sui ) , urge urinary incontinence ( uui ) and over - active bladder ( oab ) syndrome , we used data obtained from all respondents of questionnaires sent at 12 and 36  weeks gestation and 3 and 12  months post - partum . in addition , we analysed data obtained from the questionnaires sent at 36  weeks gestation and 12  months after delivery to assess the possible association between urinary symptoms and depression . we did so because the prevalence of urinary symptoms peak in the third trimester and because pelvic floor symptoms , occurring in pregnancy and persisting 1  year after delivery , may be associated with depression at this time . depressive symptoms were investigated using the center for epidemiologic studies depression scale ( ces - d ) . this scale is developed for use in non - psychiatric populations and gives an impression of depressive symptoms [ 27 , 28 ] . the total score ranges from 0 to 60 ; a higher score corresponds with more depressive symptoms . a cut - off score of 16 is frequently used as an indication of a possible clinical depression . we refer in this study to women who scored b16 on the ces - d as having depressive symptoms . urinary symptoms were assessed with the urogenital distress inventory ( udi ) [ 29 , 30 ] . this questionnaire consists of 19 questions about urogenital symptoms and the experienced discomfort of these symptoms . we looked specifically at self - reported urge and stress urinary incontinence and over - active bladder syndrome . although the udi also consists of questions on prolapse , obstructive micturition and pain and heaviness in the pelvic area , these symptoms have not been linked to depression in current literature . urge incontinence was determined by a positive answer to the question :  do you experience urine leakage related to the feeling of urgency ? stress incontinence was determined by a positive answer to the question :  do you experience urine leakage related to physical activity , coughing or sneezing ?  over - active bladder syndrome was determined when both of the following questions were answered positively :  do you experience frequent urination ?  and  do you experience a strong feeling of urgency to empty your bladder ? validated questionnaires were used to assess potential confounding variables . the dutch personality questionnaire ( dpq ) contains 133 statements , which are divided into 7 domains : inadequacy , social inadequacy , rigidity , hostility , egoism , dominance and self - esteem . the higher the score , the more these characteristics are part of the subject s personality . personality traits are stable and this questionnaire was completed at 24  weeks gestation for logistic reasons . the maudsley marital questionnaire ( mmq ) was used to measure the subjective emotional and sexual relationship of the woman with her partner . the mmq consists of 15 questions , of which 10 concern emotional aspects ( range 080 ) and 5 concern sexual aspects ( range 040 ) of the relationship . the higher the score , the worse this specific aspect of the relationship is perceived . biomedical factors included length and weight at 36  weeks gestation and 1  year after delivery , age at time of delivery , the presence of a chronic illness or back pain and the use of medication . data on mode of delivery and pregnancy - related complications ( hypertensive disorders , premature delivery , growth retardation and vaginal blood loss ) were obtained from the case files of obstetricians and midwifes . data on length and weight were transformed into a body mass index ( bmi  =  weight/(height ) ) . socioeconomic factors consisted of level of education , marital state , employment and job satisfaction . for practical reasons , the education level was dichotomised into high school or less and more than high school . behavioural factors we studied were whether participants smoked , used alcohol or were involved in leisure time physical activity in early pregnancy . changes in prevalence of depressive symptoms , uui , sui and oab between 6 and 12  weeks gestation and between 36  weeks gestation and 3 and 12  months after delivery was determined using the mcnemar tests . possible variables associated with depressive symptoms , including urinary symptoms , were analysed in women that responded to the questionnaire at 36  weeks gestation and 1  year after delivery . women with and without ces - d b16 were compared in univariate analyses using the independent samples t - test for continuous variables and chi - squared test for categorical variables . the relationship between depressive symptoms ( ces - d _ 16 ) ( dependent variable ) , urinary symptoms and potential confounders was assessed using multivariate logistic regression analysis ( stepwise forward method ) to assess whether urinary symptoms remained associated with depressive symptoms . only significantly associated variables in univariate analyses ( p  <  0.05 ) were put in the model . odds ratios ( exp ( b ) ) for continuous variables were calculated when appropriate . the hosmer and lemeshow test was used to establish the goodness of fit of the model . a p value of > 0.05 indicates that the model provides a valid representation of data . of the 672 women who started in the study at 12  weeks gestation , 642 ( 95% ) women responded to the personality questionnaire sent at 24  weeks gestation . the questionnaires at 36  weeks gestation and 3 and 12  months after delivery were answered by 511 ( 76% ) , 503 ( 75% ) and 509 ( 76% ) women , respectively . the average age at delivery was 30.0  years ( standard deviation ( sd ) 3.6  years ) . average bmi at 36  weeks gestation was 27.9  kg / m ( sd 4.1  kg / m ) . pregnancy - related complications were reported in 18.3% . in our series , urinary tract infection was not mentioned by any of the women . the prevalence rates of depressive symptoms , uui , sui and oab at different points in time during and after pregnancy are shown in table  1 . the increase in prevalence during pregnancy ( from 12 to 36  weeks gestation ) and decrease in prevalence after pregnancy ( from 36  weeks gestation to 12  months after delivery ) of all symptoms , except urge urinary incontinence , was statistically significant in the mcnemar tests ( p  <  0.05 ) . the increase in prevalence of urge incontinence during pregnancy was significant ; however , the seemingly decrease after childbirth was not significant . factors significantly associated with depressive symptoms at 36  weeks gestation in univariate analyses and in multivariate logistic regression model are shown in table  2 . many factors were significantly associated in univariate analysis ; however , in logistic regression only ( social ) inadequacy ( personality traits ) , worse sexual relationship with the partner , not being involved in leisure time physical activity , pregnancy - related complications and oab syndrome remained independently associated with depressive symptoms . the hosmer and lemeshow test provided a p value of 0.214 , which indicates a proper goodness of fit for this model . explained variance in this model ( r ) is 40.9% . at 1  year post - partum , no significant association was found between depressive and urinary symptoms in the chi - squared tests ; therefore , no logistic regression analysis was performed . table  1incidence of depressive symptoms ( ces - d    16 ) , incontinence and over - active bladder syndrome  12  weeks gestation ( % ) 36  weeks gestation ( % ) 3  months post - partum ( % ) 12  months post - partum ( % ) depressive symptoms18.220.716.712.2urge incontinence7.319.116.115.6stress incontinence20.142.226.534.3over - active bladder syndrome54.260.17.814.4table  2univariate and multivariate associated factors with depressive symptoms at 36  weeks gestation  ces - d  <  16 ( n  =  405)ces - d    16 ( n  =  106)crude or ( 95% ci)adjusted or ( 95% ci)udiurge incontinence17.4%26.7%1.73 ( 1.052.86)stress incontinence39.2%52.4%1.71 ( 1.112.63)over - active bladder syndrome57.0%73.3%2.08 ( 1.293.34)4.40 ( 1.8410.48)mmqemotionality6.62 ( 6.21)13.74 ( 11.33)1.10 ( 1.071.13)sexuality11.52 ( 6.95)16.53 ( 8.12)1.09 ( 1.061.13)1.12 ( 1.061.17)npvinadequacy8.08 ( 5.09)14.50 ( 7.79)1.17 ( 1.131.22)1.21 ( 1.131.30)social inadequacy6.89 ( 6.19)9.84 ( 6.96)1.07 ( 1.041.10)1.08 ( 1.011.16)rigidity24.65 ( 6.81)26.47 ( 5.91)1.04 ( 1.011.08)hostility12.36 ( 5.36)17.12 ( 6.71)1.14 ( 1.101.19)egoism9.03 ( 4.23)10.56 ( 4.90)1.08 ( 1.031.13)self - esteem30.30 ( 4.83)27.09 ( 4.56)0.88 ( 0.840.92)bmi ( kg / m)27.59 ( 3.65)29.22 ( 5.24)1.10 ( 1.041.15)age ( years)30.50 ( 3.67)29.66 ( 4.02)0.94 ( 0.891.00)education high school / below46.9%63.2%1.95 ( 1.253.02)unemployed4.5%12.3%3.00 ( 1.426.34)low job satisfaction5.2%15.1%3.23 ( 1.576.68)smoking7.1%16.2%2.53 ( 1.334.83)use of alcohol16.0%6.7%0.38 ( 0.170.85)no leisure time physical activity43.2%65.1%2.46 ( 1.573.83)2.83 ( 1.355.92)back pain51.9%67.0%1.90 ( 1.212.98)pregnancy related complications8.8%20.8%2.71 ( 1.385.34)3.22 ( 1.128.87)shown are significantly associated factors at the p  <  0.05 level with depressive symptoms . non - significantly associated factors are left out in this table.ces-d : center for epidemiologic studies depression scale , udi : urogenital distress inventory , mmq : maudsley marital questionnaire , dpq : dutch personality questionnaire , bmi : body mass index , or : odds ratio , 95% ci : 95% confidence interval . incidence of depressive symptoms ( ces - d    16 ) , incontinence and over - active bladder syndrome univariate and multivariate associated factors with depressive symptoms at 36  weeks gestation shown are significantly associated factors at the p  <  0.05 level with depressive symptoms . ces - d : center for epidemiologic studies depression scale , udi : urogenital distress inventory , mmq : maudsley marital questionnaire , dpq : dutch personality questionnaire , bmi : body mass index , or : odds ratio , 95% ci : 95% confidence interval . in our study , we set out to analyse the prevalence of depressive and urinary symptoms during and after pregnancy and to assess the possible association of urinary symptoms with depression , whilst controlling for psychosocial , behavioural , socioeconomic and biomedical factors . we showed a significant increase in prevalence of depressive symptoms , uui , sui and oab during pregnancy and a significant reduction in the prevalence of depressive symptoms , sui and oab after childbirth ( p  <  0.05 ) . in univariate analysis , uui , sui and the oab syndrome was significantly associated with a ces - d score of b16 at 36  weeks gestation . however , after adjusting for possible confounding factors , only the oab syndrome remained significantly associated . at 1  year after delivery , no association was found between urinary incontinence , oab syndrome and depressive symptoms . in non - pregnant women , an association is reported between depression and urinary incontinence , especially urge incontinence , and over - active bladder syndrome with and without urge incontinence [ 1519 ] . our univariate analysis also showed that urinary incontinence and over - active bladder syndrome were significantly associated with depressive symptoms . however , in multivariate analysis , we did not find an association between depressive symptoms and stress or urge urinary incontinence during or after pregnancy . on the other hand , we did find an independent significant relation between depressive symptoms and over - active bladder syndrome at 36  weeks gestation , though not 1  year after delivery . in a research in a non - pregnant population , the finding that depression at 1  year after delivery was not associated with urinary symptoms does not support this explanation . thirdly , a mutual pathologic origin of urinary incontinence and depression is proposed : both are suggested to be caused by the reduction of serotonin [ 15 , 35 ] . this suggestion is at the least dubious because serotonergic depletion as the suggested aetiology in depression has been seriously questioned . furthermore , the therapeutic effect of selective serotonin re - uptake inhibitors ( ssris ) in the treatment of depression is only slightly better than placebo . in a pregnant population , first , during the third trimester of pregnancy , the increase in cardiac output , increasing size of the uterus with compression of the bladder and sleep disturbances may all contribute to an increased voiding frequency . secondly , the definition used for over - active bladder syndrome ( combination of urgency and frequency ) has been developed for use in a non - pregnant population . because the majority of women will have frequency and urgency symptoms as part of their normal third trimester pregnancy , it is questionable if the diagnosis of oab in pregnancy has the same meaning and impact as oab in non - pregnant women . the strength of this study is that we used a prospective , longitudinal design with validated questionnaires in a large number of healthy nulliparous women . by measuring not only urogenital symptoms and depressive symptoms , but also psychosocial , behavioural , socioeconomic and biomedical factors , we were able to perform solid multivariate analysis techniques on the associations between bladder symptoms and depression . first , because of the observational , epidemiological design of the study , all information gathered through the questionnaires is subjective . although we could rule out , to a certain extend , urinary tract infection as potential confounding factor for urinary symptoms from the records of the midwife or gynecologist , we were unable to confirm the reported symptoms by means of a clinical diagnosis . however , the sensitivity of clinical tests like the stress test and also urodynamic investigation in relation to urogenital symptoms is still under debate [ 38 , 39 ] . our data have to be interpreted from a symptom - based point of view , which is most often the best there is to get out of epidemiological studies . it would be worthwhile to test our findings in a clinical setting , although the use of urodynamics during pregnancy in healthy women may turn out to be a difficult ethical question . due to the quantity and intimate nature of the questions on sexuality and pelvic floor discomfort , the response rate was 54% . however , the prevalence rates of pelvic floor problems and back pain found in this cohort are in concordance with prevalence rates in other studies and the obstetrical outcome ( mode of delivery , birth weight , etc . ) of the study population was similar to that of comparable women registered in the netherlands perinatal registry 2001 [ 13 , 40 , 41 ] . in addition , the percentage of women scoring above the cut - off score of 16 on the ces - d is similar to that found in a large american study among pregnant women . finally , the associations we found between psychosocial , behavioural , socioeconomic and biomedical factors at 36  weeks gestation have all been reported before in ante - natal and post - natal study populations [ 5 , 7 , 21 , 22 , 4245 ] . so , the chance that our results are biased by the moderate participation rate is low . a third limitation is that we did not have information on urogenital and depressive symptoms before pregnancy . we decided not to ask about previous symptoms because of the risk of recall bias . longstanding pre - pregnancy depressive disorders or urogenital symptoms may affect the prevalence rate recorded in pregnancy , but it is questionable if it would affect the associations we studied . our main conclusion that there is no association between uui , sui and depressive symptoms during and after pregnancy was reached after multivariate adjustment in which many factors were accounted for . finally , the prevalence of depressive symptoms was measured with the ces - d and diagnosis of depression could therefore differ from diagnosis obtained through interview following the dsm - iv criteria . however , the ces - d is a widely used questionnaire with adequate sensitivity and specificity , gives a good indication of depressive symptoms and is very suitable for large cohort studies . we found significantly higher rates of depressive symptoms , sui and oab syndrome during pregnancy than after childbirth . after controlling for other associated factors , we found an independent association between depressive symptoms and the oab syndrome in pregnancy but not with urinary incontinence . this association between oab syndrome and depressive symptoms is lost after pregnancy , so it is likely that pregnancy - related factors have confounded this association . in general practice , this information on the natural course of the oab syndrome , and its lack in causing major depressive symptoms after childbirth , can be used to counsel women who are confronted with these problems during pregnancy .
depressive symptoms and urinary symptoms are both highly prevalent in pregnancy . in the general population , an association is reported between urinary symptoms and depressive symptoms . the association of depressive and urinary symptoms has not yet been assessed in pregnancy . in this study , we assessed ( 1 ) the prevalence of depressive symptoms , over - active bladder ( oab ) syndrome , urge urinary incontinence ( uui ) and stress urinary incontinence ( sui ) during and after pregnancy using the center for epidemiologic studies depression scale ( ces - d ) and the urogenital distress inventory ( udi ) and ( 2 ) the association of depressive symptoms with urinary incontinence and over - active bladder syndrome during and after pregnancy , controlling for confounding socioeconomic , psychosocial , behavioural and biomedical factors in a cohort of healthy nulliparous women . 
 our data show a significant increase in prevalence of depressive symptoms , uui , sui and oab during pregnancy and a significant reduction in prevalence of depressive symptoms , sui and oab after childbirth . 
 uui prevalence did not significantly decrease after childbirth . in univariate analysis , 
 urinary incontinence and the oab syndrome were significantly associated with a ces - d score indicative of a possible clinical depression at 36  weeks gestation . however , after adjusting for possible confounding factors , only the oab syndrome remained significantly associated ( or 4.4 [ 1.810.5 ] ) . 
 no association was found between depressive and urinary symptoms at 1  year post - partum . 
 only oab was independently associated with depressive symptoms during pregnancy . 
 possible explanations for this association are discussed .