Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017

A global perspective: Access to mental health care for perinatal populations

Perinatal mental health care differs around the world. We provide a global perspective on the current status of service provision, barriers and facilitators to access, and strategies to improve access in high-income and low- and middle-income countries across five continents (Asia, Africa, Europe, North America and South America). Many of the countries considered do not have universal healthcare coverage. This poses a challenge to perinatal mental health care access. However, there are other social and structural barriers to access, including stigma and other sources of marginalization and discrimination. Yet there are opportunities discussed herein to learn more about what perinatal mental health services work for what populations* and in what circumstances, by adopting a global lens to examine innovative solutions utilized across geographical settings.

Effectiveness of online psychological interventions to prevent perinatal depression in fathers and non-birthing partners: A systematic review and meta-analysis of randomized controlled trials

Little is known about the effectiveness of online preventive interventions for paternal perinatal depression (PPD). This systematic review (SR) and meta-analysis (MA) of randomized controlled trials (RCTs) evaluated the effectiveness of online psychological interventions to prevent PPD in fathers and non-birthing partners. The PRISMA 2020 guidelines were followed. The search was conducted in eight electronic databases and other sources from inception to 12 May 2023. The pooled standardized mean difference (SMD) was computed using random-effect models. Seven RCTs were included in the SR and 6 were included in the MA, representing 1.042 fathers from five different countries. No trials focused on non-birthing partners were found. The pooled SMD was -0.258 [95 % confidence interval - 0.513 to -0.004; p < 0.047]. The heterogeneity was moderate (I2 = 51 %; 95%CI [0 % to 81 %]) and nonsignificant (p = 0.070). However, sensitivity analyses showed that the effectiveness was stable only when the fixed effect model and the Egger's g were used to estimate the pooled SMD. No publication bias was found. Only two RCTs had an overall low risk of bias assessed by using the Cochrane ROB 2.0 tool. The quality of evidence based on GRADE was very low. In conclusion, online psychological interventions may be effective for the prevention of PPD. More high-quality evidence is warranted.

Patterns of disease-modifying therapy utilization before, during, and after pregnancy and postpartum relapses in women with multiple sclerosis

BACKGROUND

Pregnancy is a common consideration for people with multiple sclerosis (pwMS); MS onset is typically between 20 and 45 years of age, during potential child-bearing years. Pregnancy and postpartum care are a significant factor influencing disease-modifying therapy (DMT) selection for many pwMS. To date, few DMTs are considered safe to continue during pregnancy and real-world treatment patterns before, during, and after pregnancy remain uncharacterized. Evolving guidance is needed regarding how to optimize management of the pregnancy and postpartum periods considering the changing DMT landscape. This analysis in two large claims databases describes DMT utilization for the treatment of MS before, during, and after pregnancy and relapse patterns during pregnancy and postpartum.

METHODS

In this retrospective, observational study, the US MarketScan Commercial and Medicaid claims database was assessed for female patients aged 18-55 years with ≥1 insurance claim submitted under the diagnosis code of MS from 01 January 2016-30 April 2021 and continuous enrollment eligibility from ≥6 months prior to pregnancy date (preconception) through 6 months of follow-up following delivery (postpartum period). Comorbid conditions were examined preconception and postpartum, including anxiety and depression. Moderate/severe relapse was defined as MS-related hospitalization, or an outpatient visit and one claim within 7 days of the visit with steroids or total plasma exchange.

RESULTS

A total of 944 patients (mean [standard deviation] age, 32.4 [5.0] years) were eligible; 688 (73%) were commercially insured and 256 (27%) received Medicaid. Compared with commercially-insured patients, use of DMTs was lower among Medicaid patients at 6 months preconception (25.4% vs 40.4%; p < 0.001), with similar patterns observed both during pregnancy and postpartum. Overall, prevalence of DMT use declined sharply during pregnancy, from 36.3% of patients in the 6 months preconception to 17.9%, 5.3%, and 5.8% in trimesters 1, 2 and 3, respectively. Postpartum DMT utilization increased to 20.9% at 0-3 months and 24.4% at 4-6 months. Of all patients in the preconception period, the most frequently used DMTs were glatiramer acetate (14.3%), dimethyl fumarate (6.0%), interferon (5.2%), and natalizumab (4.9%). Due to small sample size, information was limited for anti-CD20s and alemtuzumab. The proportion of patients with any moderate/severe relapse declined over pregnancy (preconception, n = 82 [8.7%]; pregnancy, n = 25 [2.6%]), but increased postpartum (n = 94 [10.0%]). Of the 889 patients who stopped DMT during pregnancy, the risk of postpartum relapses was lower in the patients who resumed DMT postpartum (10/192) than in patients who did not (76/697) (5.2% vs 10.9%; odds ratio, 0.455 [95% confidence interval 0.216-0.860], p = 0.018). Cases of postpartum depression and anxiety were significantly lower in commercially-insured patients vs Medicaid patients (postpartum depression, 13.7% vs 27.0%, p < 0.01; postpartum anxiety, 16.3% vs 30.5%, p < 0.01).

CONCLUSION

DMT utilization declined sharply during pregnancy; it gradually increased postpartum but remained below pre-pregnancy use. The proportion of pwMS experiencing a moderate/severe relapse and number of relapses declined over pregnancy but increased postpartum. Reinitiation of DMT during the postpartum period was associated with lower risk of relapses, supporting a role for early reinitiation of DMT postpartum.

STUDY SUPPORTED BY

Biogen.

Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? Findings from a retrospective cohort study in Maryland: 2016-2019

BACKGROUND

Perinatal mental health conditions and substance use are leading causes, often co-occurring, of pregnancy-related and pregnancy-associated deaths in the United States. This study compares odds of hospitalization with a mental health condition or substance use disorder or both during the first year postpartum between patients with and without severe maternal morbidity (SMM) during delivery hospitalization.

Methods

Data are from the Maryland's State Inpatient Database and include patients with a delivery hospitalization during 2016-2018 (n = 197,749). We compare rate of hospitalization with a mental health condition or substance use disorder or both at 42 days and 42 days to 1 year postpartum by occurrence of SMM during the delivery hospitalization. We use multivariable logistic regression to derive the odds of hospitalization with each outcome for patients by SMM status, adjusted for patient sociodemographic characteristics, presence of mental health condition or substance use disorder diagnoses during the delivery hospitalization, and delivery outcome. SMM, mental health conditions, and substance use disorders are identified using ICD-10 diagnosis and procedure codes.

RESULTS

Overall, 5,793 patients (2.9%) who delivered during 2016-2018 experienced hospitalization in the year following delivery. Among these patients, 24.3% (n = 1,410) had a mental health condition diagnosis, 10.6% (n = 619) had a substance use disorder diagnosis, and 9.8% (n = 570) had co-occurring mental health condition and substance use disorder diagnoses. Patients with SMM had 3.7 times the odds (95% CI 2.7, 5.2) of hospitalization with a mental health condition diagnosis, 2.7 times the odds (95% CI 1.6, 4.4) of a hospitalization with substance use disorder diagnosis, and 3.0 times the odds (95% CI 1.8, 4.8) of hospitalization with co-occurring mental health condition and substance use disorder diagnoses during the first-year postpartum adjusting for covariates.

CONCLUSION

Patients who experience SMM during their delivery hospitalization had higher odds of hospitalization with a mental health condition, substance use disorder, and co-occurring mental health condition and substance use disorder in the one-year postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and warm handoffs -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients.

Sacred space: a qualitative interpretive meta-synthesis of women's experiences of supportive birthing environments

BACKGROUND

In the United States there are roughly three million births a year, ranging from cesarean to natural births. A major aspect of the birthing process is related to the healing environment, and how that helps or harms healing for the mother and child. Using the theoretical framework, Theory of Supportive Care Settings (TSCS), this study aimed to explore what is necessary to have a safe and sacred healing environment for mothers.

METHOD

This study utilized an updated Qualitative Interpretive Meta-synthesis (QIMS) design called QIMS-DTT [deductive theory testing] to answer the research question, What are mother's experiences of environmental factors contributing to a supportive birthing environment within healthcare settings?

RESULTS

Key terms were run through multiple databases, which resulted in 5,688 articles. After title and abstract screening, 43 were left for full-text, 12 were excluded, leaving 31 to be included in the final QIMS. Five main themes emerged from analysis: 1) Service in the environment, 2) Recognizing oneself within the birthing space, 3) Creating connections with support systems, 4) Being welcomed into the birthing space, and 5) Feeling safe within the birthing environment.

CONCLUSIONS

Providing a warm and welcoming birth space is crucial for people who give birth to have positive experiences. Providing spaces where the person can feel safe and supported allows them to find empowerment in the situation where they have limited control.

Dynamic Associations Among Sleep, Emotion Dysregulation, and Desire to Live in a Perinatal Sample

OBJECTIVE

The present study prospectively examined dynamic associations among sleep, emotion dysregulation, and desire to live during the perinatal transition, as it was theorized that these factors may contribute to the emergence of postpartum suicide risk.

METHOD

Ninety-four women ( Mage = 29.2 years; 23.4% Latina) wore wrist actigraphs and completed twice daily surveys for 7 days during the third trimester of pregnancy, 6 weeks postpartum, and 4 months postpartum. Multilevel, change-as-outcome models were built to examine changes in attractor dynamics among sleep, emotion dysregulation, and desire to live, as well as if sleep-emotion dysregulation dynamics differed based on participants' desires to live.

RESULTS

From pregnancy to 6 weeks postpartum, emotion dysregulation ( B = -0.09, p = .032) and desire to live ( B = -0.16, p < .001) exhibited more stable temporal patterns around higher emotion dysregulation and lower desire to live. Compared to women who reported consistently high desires to live, those who experienced fluctuations in their desires to live exhibited lower, more stable sleep efficiency during pregnancy ( B = -0.90, p < .001). At 4 months postpartum, those with fluctuating desires to live exhibited a coupling dynamic whereby low sleep efficiency predicted increases in emotion dysregulation ( B = -0.16, p = .020).

CONCLUSIONS

This study was the first to examine nonlinear dynamics among risk factors for postpartum suicide, which may be evident as early as pregnancy and 6 weeks postpartum. Sleep health, in particular, warrants further exploration as a key susceptibility factor in the emergence of postpartum suicide risk.

PREREGISTRATION

Open Science Framework ( https://osf.io/qxb75/?view_only=799ffe5c048842dfb89d3ddfebaa420d ).

Disparities in Utilization and Delivery Outcomes for Women with Perinatal Mood and Anxiety Disorders

Perinatal mood and anxiety disorders (PMAD), which include depression and/or anxiety in the year before and/or after delivery, are common complications of pregnancy, affecting up to one in four perinatal individuals, with costs of over $15 billion per year in the US. In this paper, we provide an overview of the disparities in utilization and delivery outcomes for individuals with perinatal mood and anxiety disorders in the US. In addition, we discuss the current US screening and treatment guidelines as well as the high societal costs of illness of PMAD for both perinatal individuals and children. Finally, we outline opportunities for quality improvement of PMAD care in the US, including leveraging increased engagement with healthcare system during prenatal care, working toward a more cohesive national strategy to address PMAD, leaning into evidence-based policymaking through collaboration with a panel of experts, and generating state-level profiles focused on PMAD.

Perinatal Mental Health: The Need For Broader Understanding And Policies That Meet The Challenges

Perinatal mental health is gaining recognition as a key antecedent of adverse maternal and child outcomes as the United States experiences a maternal mortality and morbidity crisis. Recent policy efforts have attempted to mitigate adverse outcomes through legislation such as the Taskforce Recommending Improvements for Unaddressed Mental Perinatal and Postpartum Health (TRIUMPH) for New Moms Act of 2021 and postpartum coverage through Medicaid expansion. Even with progress, perinatal mental health policy continues to grapple with a basic truth: The United States lacks an overarching health care system capable of meeting the mental health care needs of perinatal people and their families.  Moreover, the burden of undiagnosed and untreated perinatal mental health challenges remains greatest among racially minoritized populations, such as Black, Asian, and multiracial people. A broader understanding of perinatal mental health is needed, grounded in the tenets of reproductive justice. From this perspective, we articulate specific policies to meet perinatal mental health challenges and promote thriving for birthing people and their families.

Prenatal and postnatal influences on behavioral development in a mouse model of preconceptional stress

Depression during pregnancy is detrimental for the wellbeing of the expectant mother and can exert long-term consequences on the offspring's development and mental health. In this context, both the gestational environment and the postpartum milieu may be negatively affected by the depressive pathology. It is, however, challenging to assess whether the contributions of prenatal and postnatal depression exposure are distinct, interactive, or cumulative, as it is unclear whether antenatal effects are due to direct effects on fetal development or because antenatal symptoms continue postnatally. Preclinical models have sought to answer this question by implementing stressors that induce a depressive-like state in the dams during pregnancy and studying the effects on the offspring. The aim of our present study was to disentangle the contribution of direct stress in utero from possible changes in maternal behavior in a novel model of preconceptional stress based on social isolation rearing (SIR). Using a cross-fostering paradigm in this model, we show that while SIR leads to subtle changes in maternal behavior, the behavioral changes observed in the offspring are driven by a complex interaction between sex, and prenatal and postnatal maternal factors. Indeed, male offspring are more sensitive to the prenatal environment, as demonstrated by behavioral and transcriptional changes driven by their birth mother, while females are likely affected by more complex interactions between the pre and the postpartum milieu, as suggested by the important impact of their surrogate foster mother. Taken together, our findings suggest that male and female offspring have different time-windows and behavioral domains of susceptibility to maternal preconceptional stress, and thus underscore the importance of including both sexes when investigating the mechanisms that mediate the negative consequences of exposure to such stressor.

The efficacy of zuranolone in postpartum depression and major depressive disorder: a review & number needed to treat (NNT) analysis

INTRODUCTION

Major depressive disorder (MDD) is a common and debilitating mental illness. Postpartum depression (PPD) impacts women globally and is one of the most common complications of childbirth that is underdiagnosed and undertreated, adversely impacting the mental health of women, children, and partners.Available antidepressant medications require weeks to months before showing effect. In this setting, zuranolone, an oral neuroactive steroid and a positive allosteric modulator of GABAA receptors, is an attractive alternative as a rapid-acting antidepressant treatment.

AREAS COVERED

This article reviews zuranolone (SAGE217), focusing on available clinical studies in individuals with PPD and MDD. This paper adds to the extant literature by presenting the efficacy data as Number Needed to Treat (NNT) to facilitate indirect comparisons with other antidepressants.

EXPERT OPINION

Zuranolone is a novel rapid-acting (i.e. two week course) oral antidepressant for the treatment of adults with PPD with ongoing clinical trials evaluating its efficacy in adults with MDD. Zuranolone is well tolerated with no significant safety concerns in any clinical trials completed to date. Zuranolone will be scheduled by the Drug Enforcement Agency (DEA).

Epigenome-wide association studies of prenatal maternal mental health and infant epigenetic profiles: a systematic review

Prenatal stress and poor maternal mental health are associated with adverse offspring outcomes; however, the biological mechanisms are unknown. Epigenetic modification has linked maternal health with offspring development. Epigenome-wide association studies (EWAS) have examined offspring DNA methylation profiles for association with prenatal maternal mental health to elucidate mechanisms of these complex relationships. The objective of this study is to provide a comprehensive, systematic review of EWASs of infant epigenetic profiles and prenatal maternal anxiety, depression, or depression treatment. We conducted a systematic literature search following PRISMA guidelines for EWAS studies between prenatal maternal mental health and infant epigenetics through May 22, 2023. Of 645 identified articles, 20 fulfilled inclusion criteria. We assessed replication of CpG sites among studies, conducted gene enrichment analysis, and evaluated the articles for quality and risk of bias. We found one repeated CpG site among the maternal depression studies; however, nine pairs of overlapping differentially methylatd regions were reported in at least two maternal depression studies. Gene enrichment analysis found significant pathways for maternal depression but not for any other maternal mental health category. We found evidence that these EWAS present a medium to high risk of bias. Exposure to prenatal maternal depression and anxiety or treatment for such was not consistently associated with epigenetic changes in infants in this systematic review and meta-analysis. Small sample size, potential bias due to exposure misclassification and statistical challenges are critical to address in future efforts to explore epigenetic modification as a potential mechanism by which prenatal exposure to maternal mental health disorders leads to adverse infant outcomes.

Suicidal ideation and depressive symptoms in an urban post-partum maternity setting: a retrospective cohort study

BACKGROUND

Fifteen percent of women worldwide experience depression in the perinatal period. Suicide is now one of the leading causes of maternal mortality in developed countries. Internationally, many healthcare systems screen post-natal women for depressive symptoms and suicidal ideation to facilitate early assessment and intervention. To our knowledge, no Irish data exists on the prevalence of suicidal ideation in this cohort.

AIMS

To evaluate the prevalence of suicidal ideation and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) in post-natal women attending a large Dublin maternity hospital.

METHODS

A retrospective cohort study was conducted. Women were randomly selected by delivery date over a 6 month period. Demographic and medical information was collected from their booking visit and discharge summary data. EPDS results at discharge post-partum were examined.

RESULTS

Data was collected on 643 women. Post-partum, 19 women (3.4%) had experienced suicidal ideation in the previous 7 days. Just over half of these women also had high EPDS scores (>12). Overall, 29 women (5.2%) screened positive for depression (EPDS score > 12).

CONCLUSIONS

The rate of suicidal ideation is in line with the published international data and emphasises the need for all clinicians to inquire about such thoughts. Training of midwifery and obstetric staff is required. Maternity units should have a policy on the management of suicidal ideation and risk. The prevalence of depressive symptoms post-partum was comparatively low in our study. This could suggest that antenatal screening and early intervention, which are integral parts of the perinatal mental health service, are effective. However, due to limitations of the study, it could also reflect an under-representation of depressive symptom burden in this cohort.

Using a Patient Educational Video to Improve Knowledge of Maternal Mortality Warning Signs: A Randomized Controlled Trial

OBJECTIVE

To determine whether a community-informed, language-concordant postpartum video education campaign, developed with community input, improves patients' knowledge of warning signs for postpartum maternal mortality (infection, hemorrhage, hypertensive disorders, and postpartum depression) compared with routine discharge procedures.

METHODS

A single-center, investigator-blinded, parallel-group randomized controlled trial of postpartum individuals who delivered at a large, urban, tertiary care hospital. Eligible participants were enrolled and completed a baseline knowledge questionnaire. After delivery, they were randomized to routine discharge education (control) or routine education plus video education (intervention). After discharge education, patient knowledge was again assessed in both groups before participants left the hospital. The primary outcome was the percentage of participants who showed improvement in their knowledge, measured by the number of correct questionnaire responses after education compared with their baseline, assessed as a binary outcome. A sample size of 150 (75 per group) was planned to detect a 25% absolute increase in the frequency of the primary outcome.

RESULTS

From July to August 2022, 296 participants were screened and 200 were randomized (100 per group). Eighty-two percent of participants had college or graduate education, and 71.5% had commercial insurance. There was no significant difference in baseline characteristics. There was no statistically significant difference in the percentage of participants who improved their scores between the baseline and posteducation questionnaires (64.5% vs 50.0%, P =.09). However, the median posteducation questionnaire total score was significantly higher in the video education group (14 [interquartile range 12-15] vs 13 [interquartile range 12-14], P =.003). In addition, they more frequently reported that video education was "very helpful" (83.9% vs 72.5%, P =.23) and that they were "very satisfied" with their education (86.1% vs 75.5%, P =.29).

CONCLUSION

Enhanced postpartum education through a novel video did not result in a statistically significant difference in frequency of improved score on the posteducation questionnaires but was associated with increased satisfaction with care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT05159726.

Association of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act on severe maternal morbidity

OBJECTIVE

This study aimed to characterize the association between Mental Health Parity and the Affordable Care Act and rates of severe maternal morbidity among a population of commercially insured individuals, including individuals with and without perinatal mood and anxiety disorders.

METHODS

We conducted a serial, cross-sectional analysis of individuals with an inpatient delivery in Optum's Clinformatics® Data Mart Database from 2008 to 2021. We applied an interrupted time series model with autoregressive integrated moving average to evaluate changes in quarterly severe maternal morbidity rates.

RESULTS

Adjusted severe maternal morbidity rates declined from 167.2 (95%CI: [152.6, 181.9]) per 10,000 deliveries in the first quarter of 2008 to 98.2 (95%CI: [83.5, 112.8]) per 10,000 deliveries in the last quarter of 2021. Severe maternal morbidity rates remained higher, but declined to a greater degree, among those with perinatal mood and anxiety disorders (435.6, 95%CI: [379.9, 491.3], to 165.0, 95%CI: [109.3, 220.8] per 10,000 deliveries) compared to those without (153.0, 95%CI: [140.7, 165.3] to 81.8, 95%CI: [69.6, 94.1] per 10,000 deliveries).

CONCLUSION

The observed association suggests implementation of Mental Health Parity and Affordable Care Act may have played a role in lowering rates of severe maternal morbidity, particularly among individuals with perinatal mood and anxiety disorders.

Advantages and disadvantages of using theory-based versus data-driven models with social and behavioral determinants of health data

OBJECTIVE

Theory-based research of social and behavioral determinants of health (SBDH) found SBDH-related patterns in interventions and outcomes for pregnant/birthing people. The objectives of this study were to replicate the theory-based SBDH study with a new sample, and to compare these findings to a data-driven SBDH study.

MATERIALS AND METHODS

Using deidentified public health nurse-generated Omaha System data, 2 SBDH indices were computed separately to create groups based on SBDH (0-5+ signs/symptoms). The data-driven SBDH index used multiple linear regression with backward elimination to identify SBDH factors. Changes in Knowledge, Behavior, and Status (KBS) outcomes, numbers of interventions, and adjusted R-squared statistics were computed for both models.

RESULTS

There were 4109 clients ages 13-40 years. Outcome patterns aligned with the original research: KBS increased from admission to discharge with Knowledge improving the most; discharge KBS decreased as SBDH increased; and interventions increased as SBDH increased. Slopes of the data-driven model were steeper, showing clearer KBS trends for data-driven SBDH groups. The theory-based model adjusted R-squared was 0.54 (SE = 0.38) versus 0.61 (SE = 0.35) for the data-driven model with an entirely different set of SBDH factors.

CONCLUSIONS

The theory-based approach provided a framework to identity patterns and relationships and may be applied consistently across studies and populations. In contrast, the data-driven approach can provide insights based on novel patterns for a given dataset and reveal insights and relationships not predicted by existing theories. Data-driven methods may be an advantage if there is sufficiently comprehensive SBDH data upon which to create the data-driven models.

Prenatal Stress Exposure Amplifies Effect of Maternal Suicidal Ideation on Early Childhood Behavioral Trajectories

The in utero environment influences fetal development and may predispose to disease later in life. This study examines whether maternal suicidal ideation during pregnancy is associated with children's behavioral trajectories across early childhood, and whether prenatal maternal traumatic stress accelerates the trajectories. The study included mother-child dyads (N = 331, 51.1% boys) from the longitudinal Stress In Pregnancy study; 31.1% (n = 103) mothers were Exposed to Superstorm Sandy. During their second trimester, 12.4% (n = 41) women reported suicidal ideation during pregnancy. Mothers completed the Behavior Assessment Scale for Children-2 annually from ages 2- to 6-years-old to assess multiple behavioral domains. Hierarchical linear modeling estimated within-person longitudinal trajectories of clinical behaviors, and between-person effects of maternal suicidal ideation and disaster-related stress in utero on changes in child behavior. For children exposed to both risks, Atypical behaviors (i.e., unusual behaviors, social disconnection) increased linearly across early childhood. Exposure to Superstorm Sandy and maternal suicidal ideation were independently associated with non-linear increases in Anxiety severity and maternal suicidal ideation during pregnancy was associated with a linear increase in Attention problems across early childhood. Maternal suicidal ideation during pregnancy is associated with increased risk for a range of behavioral and emotional difficulties in early childhood and the trajectory of atypical behaviors was amplified by disaster-related traumatic stress. Findings highlight the need for health professionals to screen for suicidal ideation among their pregnant patients. Pregnant women who experience severe stress may require additional monitoring and support to reduce risk for poorer early childhood outcomes.

A sum of its parts: A systematic review evaluating biopsychosocial and behavioral determinants of perinatal depression

Introduction

Depression is one of the most common yet underdiagnosed perinatal complications and our understanding of the pathophysiology remains limited. Though perinatal depression is considered to have a multifactorial etiology, integrative approaches to investigation are minimal. This review takes an integrative approach to systematically evaluate determinants and potential interactions among determinants of perinatal depression across four domains (i.e., biological, behavioral, environmental, social) and appraise the quality of methods applied.

Methods

Four databases (i.e., PubMed, CINAHL, APA PsycInfo, and Web of Science) were systematically searched to identify studies examining determinants of perinatal depression in adult perinatal persons (≥ 18 years). Articles were excluded if the outcomes were not focused on perinatal persons and depression or depression symptoms, the evaluation of depression was specific to a discrete facet of the perinatal period with probable psychological consequences (e.g., abortion, fetal/infant loss, adoption), or was considered grey literature. The Critical Appraisal Skills Programme and AXIS tools were used to guide and standardize quality appraisal assessments and determine the level of risk of bias.

Results

Of the 454 articles identified, 25 articles were included for final review. A total of 14 categories of determinants were investigated: biological (5), behavioral (4), social and environmental (5). Though only 28% of studies simultaneously considered determinants under more than one domain, a pattern of interactions with the tryptophan pathway emerged when determinants across domains were aggregated. Concerns for risk of bias were noted or were unclear for three types of bias: 13 (52%) selection bias, 3 (12%) recall bias, and 24 (96%) measurement bias.

Conclusions

Future research is needed to explore interactions among determinants and the tryptophan pathway; to strengthen the methods applied to this area of inquiry; and to generate evidence for best practices in reporting, selecting, and applying methods for measuring determinants and perinatal depression.

Evaluation of the Michigan Clinical Consultation and Care Program: An Evidence-Based Approach to Perinatal Mental Healthcare

Mood and anxiety disorders affect pregnant individuals and their families at increased rates throughout the perinatal period. Geographic, financial, and social barriers often preclude adequate diagnosis and treatment. The aim of this manuscript is to describe the consultation and care arms of the Michigan Clinical Consultation and Care (MC3) program, a statewide program designed to facilitate access to perinatal mental healthcare for OB/Gyn patients, and to describe the participants engaged in the program, examine the predictors of participant retention, and provide preliminary data regarding participants' mental health outcomes. We enrolled 209 participants to the clinical care arm, of which 48 were lost to follow-up, while 107 remained enrolled at the time of data analysis. A total of 54 participants met their treatment goals. A total of 97% of participants asserted they were satisfied with the services they received. Black race and public insurance predicted faster attrition from the care arm treatment; risks for interpersonal violence exposure and substance use were unrelated to attrition. Preliminary mental health outcomes showed significant decreases in anxiety and depression, with the most dramatic decreases in the first month of treatment. Overall, the MC3 clinical care arm shows promising rates of adherence, excellent program satisfaction, and a positive impact on perinatal mental health, supporting continued program implementation and ongoing evaluation.

Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4

PURPOSE

To review evidence on the current understanding of mental health conditions in pregnancy and postpartum, with a focus on mood and anxiety disorders, and to outline guidelines for screening and diagnosis that are consistent with best available scientific evidence. The conditions or symptoms reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, suicidality, and postpartum psychosis. For information on psychopharmacologic treatment and management, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 5, "Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum" (1).

TARGET POPULATION

Pregnant or postpartum individuals with mental health conditions. Onset of these conditions may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on the screening and diagnosis of perinatal mental health conditions including depression, anxiety, bipolar disorder, acute postpartum psychosis, and the symptom of suicidality. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Self-harm in pregnancy and the postnatal year: prevalence and risk factors

BACKGROUND

Self-harm in pregnancy or the year after birth ('perinatal self-harm') is clinically important, yet prevalence rates, temporal trends and risk factors are unclear.

METHODS

A cohort study of 679 881 mothers (1 172 191 pregnancies) was conducted using Danish population register data-linkage. Hospital treatment for self-harm during pregnancy and the postnatal period (12 months after live delivery) were primary outcomes. Prevalence rates 1997-2015, in women with and without psychiatric history, were calculated. Cox regression was used to identify risk factors.

RESULTS

Prevalence rates of self-harm were, in pregnancy, 32.2 (95% CI 28.9-35.4)/100 000 deliveries and, postnatally, 63.3 (95% CI 58.8-67.9)/100 000 deliveries. Prevalence rates of perinatal self-harm in women without a psychiatric history remained stable but declined among women with a psychiatric history. Risk factors for perinatal self-harm: younger age, non-Danish birth, prior self-harm, psychiatric history and parental psychiatric history. Additional risk factors for postnatal self-harm: multiparity and preterm birth. Of psychiatric conditions, personality disorder was most strongly associated with pregnancy self-harm (aHR 3.15, 95% CI 1.68-5.89); psychosis was most strongly associated with postnatal self-harm (aHR 6.36, 95% CI 4.30-9.41). For psychiatric disorders, aHRs were higher postnatally, particularly for psychotic and mood disorders.

CONCLUSIONS

Perinatal self-harm is more common in women with pre-existing psychiatric history and declined between 1997 and 2015, although not among women without pre-existing history. Our results suggest it may be a consequence of adversity and psychopathology, so preventative intervention research should consider both social and psychological determinants among women with and without psychiatric history.

Adverse Perinatal Outcomes and Postpartum Suicidal Behavior in California, 2013-2018

Background: The objectives of this study were to describe trends in the prevalence of postpartum suicidal behaviors in California, 2013-2018, and to estimate associations between adverse perinatal outcomes and suicidal behaviors. Materials and Methods: We used data from a population-based cohort derived from all birth and fetal death certificates. Records were individually linked to maternal hospital discharge records for the years before and after delivery. We estimated the prevalence of postpartum suicidal ideation and attempt by year. Then, we estimated crude and adjusted associations between adverse perinatal outcomes and these suicidal behaviors. The sample included 2,563,288 records. Results: The prevalence of postpartum suicidal ideation and attempt increased from 2013 to 2018. People with postpartum suicidal behavior were younger, had less education, and were more likely to live in rural areas. A greater proportion of those with postpartum suicidal behavior were Black and publicly insured. Severe maternal morbidity, neonatal intensive care unit admission, and fetal death were associated with greater risk of ideation and attempt. Major structural malformation was not associated with either outcome. Conclusions: The burden of postpartum suicidal behavior has increased over time and is unequally distributed across population subgroups. Adverse perinatal outcomes may help identify individuals that could benefit from additional care during the postpartum period.

Maternal suicide attempts and deaths in the first year after cesarean delivery

BACKGROUND

Cesarean delivery (CD) has been associated with postpartum psychiatric disorders, but less is known about the risk of suicidal behaviors. We estimated the incidence and risk of suicide attempts and deaths during the first postpartum year in mothers who delivered via CD v. vaginally.

METHOD

All deliveries in Sweden between 1973 and 2012 were identified. The mothers were followed since delivery for 12 months or until the date of one of the outcomes (i.e. suicide attempt or death by suicide), death by other causes or emigration. Associations were estimated using Cox proportional hazards regression models.

RESULTS

Of 4 016 789 identified deliveries, 514 113 (12.8%) were CDs and 3 502 676 (87.2%) were vaginal deliveries. During the 12-month follow-up, 504 (0.098%) suicide attempts were observed in the CD group and 2240 (0.064%) in the vaginal delivery group (risk difference: 0.034%), while 11 (0.0037%) deaths by suicide were registered in the CD group and 109 (0.0029%) in the vaginal delivery group (risk difference: 0.008%). Compared to vaginal delivery, CD was associated with an increased risk of suicide attempts [hazard ratio (HR) 1.46; 95% CI 1.32-1.60], but not of deaths by suicide (HR 1.44; 95% CI 0.88-2.36).

CONCLUSIONS

Maternal suicidal behaviors during the first postpartum year were uncommon in Sweden. Compared to vaginal delivery, CD was associated with a small increased risk of suicide attempts, but not death by suicide. Improved understanding of the association between CD and maternal suicidal behaviors may promote more appropriate measures to improve maternal mental well-being and further reduce suicidal risks.

Algorithm development to improve intervention effectiveness for parents with mental health signs and symptoms

OBJECTIVES

In this study we aimed to describe and compare groups formed by a rules-based algorithm to prospectively identify clients at risk of poor outcomes in order to guide tailored public health nursing (PHN) intervention approaches.

DESIGN

Data-driven methods using standardized Omaha System PHN documentation.

SAMPLE

Clients ages 13-40 who received PHN home visiting services for both the Caretaking/parenting and Mental health problems (N = 4109).

MEASUREMENT

We applied a theory-based algorithm consisting of six rules using existing Omaha System data. We examined the groups formed by the algorithm using standard descriptive, inferential statistics, and Latent Class Analysis.

RESULTS

Clients (N = 4109) were 25.1 (SD = 5.9) years old and had an average of 7.3 (SD = 3.2) problems, 250 (SD = 319) total interventions, and 32 (SD = 44) Mental health interventions. Overall outcomes improved after PHN interventions (p < .001 for all) and having more Mental health signs/symptoms was negatively associated with outcome scores (p < .001 for all).

CONCLUSIONS

This algorithm may be helpful in identifying high-risk clients during a baseline assessment who may benefit from more intensive mental health interventions. Findings show there is value using the Omaha System for PHN documentation and algorithm clinical decision support development. Future research should focus on algorithm implementation in PHN clinical practice.

Examining the gaps in perinatal mental health care: A qualitative study of the perceptions of perinatal service providers in Canada

In Canada, access to perinatal mental health services is disparate across districts, regions, provinces, and territories. Questions remain as to how gaps in service are being experienced by Canadian service providers and clinicians. This paper examines three key questions: 1) What are the experiences of care providers with respect to the screening, identifying, and managing perinatal mental health disorders? 2) What gaps in perinatal mental health care have been identified? and 3) What approaches have been taken by providers, communities, and regions in addressing the needs of their populations? To address these questions, 435 participants from across Canada were surveyed using an online survey constructed by the research members of the CPMHC. A qualitative analysis of the data revealed three key themes: groups marginalized by the current perinatal mental health system, gaps and supports identified by communities; and systemic and policy issues. From these three themes we have identified the key components of changes required in the national approach to perinatal mental health disorders. We identify key resources that could be utilized to create policy change and provide recommendations for change.

Effectiveness of interventions to prevent perinatal depression: An umbrella review of systematic reviews and meta-analysis

BACKGROUND

To date, dozens of systematic reviews (SRs) and meta-analyses (MAs) summarize the effectiveness of preventive interventions for perinatal depression. However, the results are inconclusive, making an urgent need to step up to higher levels of evidence synthesis.

AIMS

To summarize and compare the evidence from the SR&MA examining the effectiveness of all types of interventions for preventing perinatal depression.

METHOD

PubMed, PsycINFO, Cochrane Database of Systematic Reviews and OpenGrey were searched from inception to December 2022. We selected SR&MA of randomized controlled trials (RCTs) that compared all types of preventive interventions for perinatal depression with control groups whose outcome was the reduction of depressive symptoms and/or incidence of new cases of perinatal depression (PROSPERO: CRD42020173125).

RESULTS

A total of 19 SRs and MAs evaluated 152 unique RCTs that included 83,408 women from 26 countries and five continents. The median effect size for any intervention was SMD = 0.29 (95% CI: 0.20 to 0.38). Exercise/physical activity-based, psychological, and any type of intervention showed median effect sizes of 0.43, 0.28 and 0.36, respectively. The degree of overlap among RCTs was slight. According to AMSTAR-2, 79% of them were rated as low or critically low-quality. The strength of evidence, according to GRADE, was poorly reported and, in most cases, was low.

CONCLUSIONS

Exercise/physical activity-based and psychological interventions have a small-to-medium effect on reducing perinatal depressive symptoms. There is insufficient evidence to conclude that dietary supplements and pharmacological interventions are effective in preventing perinatal depression. There is a need for high-quality SR&MA of RCTs, mainly focusing on universal preventive interventions.

The role of perinatal psychiatry access programs in advancing mental health equity

This editorial presents: 1) a review of Perinatal Psychiatry Access Programs as an integrated care model with potential for promoting perinatal mental health equity; and 2) a summary of how the model has been and can be further adapted to help achieve perinatal mental health equity in geographically diverse settings. Within the editorial, we highlight Access Programs as a promising model for promoting perinatal mental health equity. This editorial is supported by original descriptive data on the Lifeline for Moms National Network of Perinatal Psychiatric Access Programs. Descriptive data is additionally provided on three statewide Access Programs. The Access Program model, and the accompanying Network of Access Programs, is a multi-level approach demonstrating promise in reducing perinatal mental health inequities. Access Programs demonstrate potential to implement interventions to address well-documented inequities in perinatal mental healthcare access at the patient-, clinician-, practice-, community-, and policy-levels. For Access Programs to leverage their potential to advance perinatal mental health equity, systematic efforts are needed that include partnership with impacted communities and implementation teams.

Critically-timed sleep+light interventions differentially improve mood in pregnancy vs. postpartum depression by shifting melatonin rhythms

BACKGROUND

Testing the hypothesis that combined wake + light therapy improves mood in pregnant vs. postpartum depressed participants (DP) by differentially altering melatonin and sleep timing.

METHODS

Initially 89 women, 37 pregnant (21 normal controls-NC; 16 DP) and 52 postpartum (27 NCs; 25 DP), were randomized to a parallel trial of a phase-delay intervention (PDI): 1-night of early-night wake therapy (sleep 3-7 am) + 6-weeks of evening bright white light (Litebook Advantage) for 60 min starting 90 min before bedtime, vs. a Phase-advance intervention (PAI): 1-night of late-night wake therapy (sleep 9 pm-1 am) + 6-weeks of morning bright white light for 60 min within 30 min of wake time. Blinded clinicians assessed mood weekly by structured interview, and participants completed subjective ratings, a Morningness-Eveningness questionnaire, actigraphy, and collected 2 overnight urine samples for 6-sulphatoxy melatonin (6-SMT).

RESULTS

In pregnant DP, mood improved more after the PDI vs. PAI (p = .016), whereas in postpartum DP, mood improved more after the PAI vs. PDI (p = .019). After wake therapy, 2 weeks of light treatment was as efficacious as 6 weeks (p > .05). In postpartum DP, PAI phase-advanced 6-SMT offset and acrophase (p < .05), which correlated positively with mood improvement magnitude (p = .003).

LIMITATIONS

Small N.

CONCLUSIONS

Mood improved more after 2 weeks of the PDI in pregnant DP, but more after 2 weeks of PAI in postpartum DP in which improvement magnitude correlated with 6-SMT phase-advance. Thus, critically-timed Sleep + Light Interventions provide safe, efficacious, rapid-acting, well-tolerated, at-home, non-pharmaceutical treatments for peripartum DP.

Hospitalisation for non-lethal self-harm and premature mortality in the 3 years following adolescent pregnancy: Population-based nationwide cohort study

OBJECTIVE

To evaluate the risk of non-lethal self-harm and mortality related to adolescent pregnancy.

DESIGN

Nationwide population-based retrospective cohort.

SETTING

Data were extracted from the French national health data system.

POPULATION

We included all adolescents aged 12-18 years with an International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) code for pregnancy in 2013-2014.

METHODS

Pregnant adolescents were compared with age-matched non-pregnant adolescents and with first-time pregnant women aged 19-25 years.

MAIN OUTCOME MEASURES

Any hospitalisation for non-lethal self-harm and mortality during a 3-year follow-up period. Adjustment variables were age, a history of hospitalisation for physical diseases, psychiatric disorders, self-harm and reimbursed psychotropic drugs. Cox proportional hazards regression models were used.

RESULTS

In 2013-2014, 35 449 adolescent pregnancies were recorded in France. After adjustment, pregnant adolescents had an increased risk of subsequent hospitalisation for non-lethal self-harm in comparison with both non-pregnant adolescents (n = 70 898) (1.3% vs 0.2%, HR 3.06, 95% CI 2.57-3.66) and pregnant young women (n = 233 406) (0.5%, HR 2.41, 95% CI 2.14-2.71). Rates of hospitalisation for non-lethal self-harm were lower during pregnancy and higher between 12 and 8 months pre-delivery, 3-7 months postpartum and in the month following abortion. Mortality was significantly higher in pregnant adolescents (0.7‰) versus pregnant young women (0.4‰, HR 1.74, 95% CI 1.12-2.72), but not versus non-pregnant adolescents (0.4‰, HR 1.61, 95% CI 0.92-2.83).

CONCLUSIONS

Adolescent pregnancy is associated with an increased risk of hospitalisation for non-lethal self-harm and premature death. Careful psychological evaluation and support should be systematically implemented for adolescents who are pregnant.

Maternal deaths due to suicide and overdose in the state of Michigan from 2008 to 2018

BACKGROUND

Recent reports indicate that the contribution of deaths related to suicide and overdose are increasing, and may be the leading contributors to maternal mortality up to one year postpartum.

OBJECTIVE

This study aimed to provide a granular assessment of maternal deaths due to suicide or drug overdose in the state of Michigan from 2008 to 2018.

STUDY DESIGN

This retrospective study involved a secondary review of deceased patients' records from 2008 to 2018 stored at the Michigan Department of Health and Human Services through the Michigan Maternal Mortality Surveillance Program. Pregnancy-related and pregnancy-associated deaths were reviewed. A descriptive analysis of maternal characteristics and identified trends was presented in deidentified aggregate form.

RESULTS

There were 237 maternal deaths due to suicide or overdose from 2008 to 2018 included in the review. Overall, 70.9% had a documented psychiatric illness in their medical chart, with 48.1% having ≥2 psychiatric illnesses. However, only 34.5% (58/168) of these patients had documentation of taking psychotropic medication for their illness. Of those who died because of accidental or indeterminate substance overdose, 71.1% (138/194) had a known history of substance use disorder. Only 27.4% (43/157) of patients with a documented substance use disorder received medication-assisted treatment. Of those with substance overdose deaths, 42.9% had an opioid prescription, 44.3% had a benzodiazepine prescription, and 32.5% had a prescription for both. Prescription opioids were the most common substance found on postmortem toxicology report, and of these patients, 45.9% had a physician-prescribed opioid.

CONCLUSION

Most pregnant individuals had documented significant risk factors for mental illness or substance use disorder; however, very few had documented pharmacologic therapy for their psychiatric or addiction illness. There is an urgent need to implement effective multidisciplinary health system mitigation strategies that address pregnancy and its intersection with behavioral health.

Suicide crises among women and mothers during and around the time of pregnancy: Prevalence and timing of initial contact with first responders and health services

OBJECTIVES

Suicide is a leading cause of maternal mortality. Suicidality during and around the time of pregnancy can have detrimental impacts on a child's development and outcomes. This paper examines prevalence, demographic characteristics, and timing of initial contact with first responders and health services for a cohort of women who experienced suicidality during and around the time of pregnancy.

METHODS

Findings are drawn from the Partners in Prevention (PiP) study, a population-wide linked data set of suicide-related attendances by police or paramedics in Queensland, Australia. A sub-cohort of women was identified, who were between 6 months preconception and 2 years postpartum at the time of a suicide-related contact with police or paramedics (PiP-Maternal). Findings are compared to other girls and women who had a suicide-related contact with police or paramedics (PiP-Female). Prevalence, demographic characteristics, timing of contact with first responders and health services, re-presentations, and mortality are reported.

RESULTS

The PiP-Maternal cohort comprised 3020 individuals and 3400 births. Women in the PiP-Maternal cohort were younger, more likely to be of Aboriginal and/or Torres Strait Islander descent and live outside of a major city than the PiP-Female cohort. There were high rates of out-of-hours calls to police and ambulance, and similar perceived seriousness of the call between women in the PiP-Maternal and PiP-Female cohorts. Women in the PiP-Maternal cohort were less likely to be admitted to an emergency department within 24 hours, even after matching on covariates. Prevalence of suicidality for women who were pregnant and up to 2 years postpartum was 1.32% (95% CI = [1.27, 1.37]).

CONCLUSION

Vulnerabilities and high rates of contact with police or paramedics, coupled with lower levels of follow-up, highlight the critical need to improve service responses for women with mental health needs during these phases of life.

Perinatal mood and anxiety disorders: biomarker discovery using plasma proteomics

BACKGROUND

Perinatal mood and anxiety disorders encompass a range of mental health disorders that occur during pregnancy and up to 1 year postpartum, affecting approximately 20% of women. Traditional risk factors, such as a history of depression and pregnancy complications including preeclampsia, are known. Their predictive utility, however, is not specific or sensitive enough to inform clinical decision-making or prevention strategies for perinatal mood and anxiety disorders. Better diagnostic and prognostic models are needed for early identification and referral to treatment.

OBJECTIVE

This study aimed to determine if a panel of novel third-trimester plasma protein biomarkers in pregnant women can be used to identify those who have a high predisposed risk for perinatal mood and anxiety disorders within 3 months postpartum.

STUDY DESIGN

We studied 52 women (n=34 with a risk for perinatal mood and anxiety disorders and n=18 controls) among whom mental health screening was conducted at 2 time points, namely in the third trimester and again at 3 months postdelivery. An elevated perinatal mood and anxiety disorder risk was identified by screening individuals with above-validated cutoffs for depression (Edinburgh Postnatal Depression Scale ≥12), anxiety (Overall Anxiety Severity and Impairment Scale ≥7), and/or posttraumatic stress disorder (Impact of Events Scale >26) at both time points. Plasma samples collected in the third trimester were screened using the aptamer-based SomaLogic SomaScan proteomic assay technology to evaluate perinatal mood and anxiety disorder-associated changes in the expression of 1305 protein analytes. Ingenuity Pathway Analysis was conducted to highlight pathophysiological relationships between perinatal mood and anxiety disorder-specific proteins found to be significantly up- or down-regulated in all subjects with perinatal mood and anxiety disorder and in those with perinatal mood and anxiety disorders and no preeclampsia.

RESULTS

From a panel of 53 significant perinatal mood and anxiety disorder-associated proteins, a unique 20-protein signature differentiated perinatal mood and anxiety disorder cases from controls in a principal component analysis (P<.05). This protein signature included NCAM1, NRCAM, and NTRK3 that converge around neuronal signaling pathways regulating axonal guidance, astrocyte differentiation, and maintenance of GABAergic neurons. Interestingly, when we restricted the analysis to subjects without preeclampsia, a 30-protein signature differentiated perinatal mood and anxiety disorder cases from all controls without overlap on the principal component analysis (P<.001). In the nonpreeclamptic perinatal mood and anxiety disorder group, we observed increased expression of proteins, such as CXCL11, CXCL6, MIC-B, and B2MG, which regulate leucocyte migration, inflammation, and immune function.

CONCLUSION

Participants with perinatal mood and anxiety disorders had a unique and distinct plasma protein signature that regulated a variety of neuronal signaling and proinflammatory pathways. Additional validation studies with larger sample sizes are needed to determine whether some of these molecules can be used in conjunction with traditional risk factors for the early detection of perinatal mood and anxiety disorders.

Perinatal Mental Health Disorders: A Review of Lessons Learned from Obstetric Care Settings

Perinatal mental health has garnered significant attention within obstetrics over the last couple of decades as the long- and short-term morbidities of untreated perinatal mental health disorders on both the mother and fetus/neonate have become increasingly apparent. There have been major strides in increasing screening for perinatal mental health disorders, clinician comfort with prescribing common psychiatric medications, and integrating mental health professionals into prenatal care via health services approaches such as the collaborative care model. Despite these advances, however, gaps still remain in the tools used for screening and diagnosis, obstetric clinician training in diagnosis and management of perinatal mood and anxiety disorders, as well as patient access to mental health care during pregnancy and especially postpartum. Herein we review the state of perinatal mental health from the perspective of the obstetric provider and identify areas of ongoing innovation.

Trends in antenatal depression and suicidal ideation diagnoses among commercially insured childbearing individuals in the United States, 2008-2018

INTRODUCTION

Antenatal depression and suicidal ideation represent serious pregnancy-related complications, yet comprehensive estimates of the prevalence and predictors of these diagnoses among birthing people remain unclear.

OBJECTIVE

This study aimed to characterize trends in the prevalence of depression and suicidal ideation diagnoses identified among pregnant individuals prior to giving birth.

METHODS

This study included 536,647 individuals aged 15-44 years continuously enrolled in a single commercial health insurance plan for one year before childbirth from 2008 to 2018. The primary outcomes included depression or suicidal ideation based on identification of the relevant ICD-9 and ICD-10 diagnosis codes during pregnancy.

RESULTS

Rates (95 % CIs) of depression increased by 39 % from 540 (520-560) per 10,000 individuals in 2008 to 750 (730-770) per 10,000 individuals in 2018. Suicidal ideation increased by 100 % from 15 (12-18) per 10,000 individuals in 2008 to 44 (39-50) per 10,000 individuals in 2018. Black birthing people experiencing the sharpest proportional increases.

CONCLUSIONS

The prevalence of depression and suicidal ideation occurring during pregnancy substantially increased over a ten-year period. Further, suicidal ideation diagnosis increased the most for among Black birthing people compared to all groups, resulting in a need for future studies in this area to determine the reasons for an increase in diagnosis and any change in resulting treatment of follow up.

Postpartum Psychosis

PURPOSE OF REVIEW

Postpartum psychosis is a psychiatric emergency that can affect the health and life of mothers, infants, and families. Postpartum psychosis (PPP) is distinct from non-postpartum psychosis in many ways, and it is crucial to study and understand PPP to identify, treat, and possibly prevent this condition. We therefore sought to review the latest research findings about PPP with the intention of updating readers about the latest evidence base.

RECENT FINDINGS

Multiple physiologic pathways have been implicated in the development of PPP, and further understanding these pathways may allow for early detection and treatment. Risk assessment and treatment should include consideration of the woman patient but also the mother-infant dyad and the larger family. It is our hope that this review of research updates in postpartum psychosis may inform clinical practice and promote specialized, evidence-based diagnosis, risk assessment, and treatment.

Disability and suicidal behaviors among women of reproductive age

Limited research exists on suicidal behaviors among women with disabilities. This study examined disability, suicidal behaviors, and associated health determinants among non-pregnant women of reproductive age. Data from the 2015-2019 National Survey on Drug Use and Health (n = 76,750) were used to estimate associations between disability and suicidal behaviors and evaluate the effects of health determinants on suicidal behaviors among non-pregnant women of reproductive age with disabilities. Approximately 22% of non-pregnant women of reproductive age with disabilities reported suicidal behaviors compared to only 4.3% of women without disabilities. Women with disabilities had greater adjusted odds of past-year suicidal behaviors (AOR 1.73; 95% CI 1.60-1.87) than those without disabilities. Psychological distress (OR 3.66; 95% CI 2.98-4.49), major depressive episode (OR 3.22; 95% CI 2.82-3.67), unmet perceived mental health need (OR 2.29; 95% CI 1.98-2.65), age 18-25 years (OR 1.65; 95% CI 1.43-1.92), and illicit drug use (OR 1.40; 95% CI 1.20-1.64) were significantly associated with higher odds of suicidal behaviors, and specifically suicidal ideation, among women with disabilities. Non-pregnant women of reproductive age with disabilities are at increased risk for exhibiting suicidal behaviors. Better understanding of suicidal behaviors among women with disabilities can assist public health officials and medical professionals in developing meaningful prevention, detection, and intervention programs.

Project BETTER: Preliminary Feasibility and Acceptability of a Technology-Delivered Educational Program for Pregnant and Postpartum People with Opioid Use Disorder

Background

Postpartum people with opioid use disorder (OUD) report feeling underprepared for the pregnancy to postpartum transition. We developed a novel, technology-delivered educational intervention for pregnant and parenting people with OUD to address this gap. This study provides a theoretically grounded assessment of the feasibility and acceptability of a new technology-delivered educational intervention (Project BETTER) for pregnant and parenting people receiving medication for OUD (MOUD).

Materials and Methods

Pregnant and postpartum people receiving MOUD were recruited from a perinatal addiction clinic research registry to pilot test the technology-delivered intervention. Participants completed one of three modules (Postpartum Transition, Neonatal Opioid Withdrawal Syndrome, or Child Welfare Interactions) and a survey assessing acceptability based on the theoretical framework of acceptability (TFA). We measured feasibility using process, resource, management, and scientific assessments. Demographics were self-reported. Clinical characteristics were abstracted from the medical record.

Results

Feasibility was promising, with 17 of 28 participants approached (61%) agreeing to participate; 70% of these participants (N = 12; 58% White and 23% Black, all with public insurance) completed an intervention module and the study assessments, and all reported understanding how the modules worked. Acceptability was strong, with median ratings of 4 or 5 on a 5-point scale for all positively scored TFA domains. Compared to learning from a provider, participants also reported feeling more comfortable and less stigmatized learning from the intervention.

Conclusion

Our theoretically grounded assessment suggests high feasibility and acceptability for Project BETTER, and provides justification for further evaluation in a clinical trial setting. Technology-delivered educational interventions may help reduce stigma and enhance prenatal education.

The Association between NICU Admission and Mental Health Diagnoses among Commercially Insured Postpartum Women in the US, 2010-2018

Maternal mental health (MH) conditions represent a leading cause of preventable maternal death in the US. Neonatal Intensive Care Unit (NICU) hospitalization influences MH symptoms among postpartum women, but a paucity of research uses national samples to explore this relationship. Using national administrative data, we examined the rates of MH diagnoses of anxiety and/or depression among those with and without an infant admitted to a NICU between 2010 and 2018. Using generalized estimating equation models, we explored the relationship between NICU admission and MH diagnoses of anxiety and/or depression, secondarily examining the association of NICU length of stay and race/ethnicity with MH diagnoses of anxiety and/or depression post NICU admission. Women whose infants became hospitalized in the NICU for <2 weeks had 19% higher odds of maternal MH diagnoses (aOR: 1.19, 95% CI: 1.14%−1.24%) and those whose infants became hospitalized for >2 weeks had 37% higher odds of maternal MH diagnoses (aOR: 1.37 95% CI: 1.128%−1.47%) compared to those whose infants did not have a NICU hospitalization. In adjusted analyses, compared to white women, all other race/ethnicities had significantly lower odds of receiving a maternal MH condition diagnosis [Black (aOR = 0.76, 0.73−0.08), Hispanic (aOR = 0.69, 0.67−0.72), and Asian (aOR: 0.32, 0.30−0.34)], despite higher rates of NICU hospitalization. These findings suggest a need to target the NICU to improve maternal MH screening, services, and support while acknowledging the influence of social determinants, including race and ethnicity, on health outcomes.

Diagnosis and Management of Perinatal Depression

Perinatal depression is a mood disorder that may occur during pregnancy or within a year after childbirth. It can be disabling for the birthing parent and cause attachment and developmental problems for the infant. A host of risk factors, including genetics, reproductive history, and life experiences, are associated with perinatal depression. With validated screening tools, health care providers can assess individuals, initiate treatment, and/or refer as appropriate. Successful treatment, which may include modalities such as cognitive behavioral therapy and/or pharmacologic therapies, helps individuals maintain a sense of control, develop self-confidence, take control of their thinking, and learn coping skills. Integrative therapies and lifestyle changes have some success but may not be adequate for many individuals. Patients may benefit from providers learning and initiating cognitive behavioral therapy techniques while awaiting therapy.

Prevalence of Bipolar Disorder in Perinatal Women: A Systematic Review and Meta-Analysis

Objective: To estimate overall prevalence of bipolar disorder (BD) and the prevalence and timing of bipolar-spectrum mood episodes in perinatal women.

Data Sources: Databases (PubMed, Scopus, PsycINFO, CINAHL, Cochrane, ClincalTrials.gov) were searched from inception to March 2020.

Study Selection: Included studies were original research in English that had (1) populations of perinatal participants (pregnant or within 12 months postpartum), aged ≥ 18 years, and (2) a screening/diagnostic tool for BD. Search terms described the population (eg, perinatal), illness (eg, bipolar disorder), and detection (eg, screen, identify).

Data Extraction: Study design data, rates, and timing of positive screens/diagnoses and mood episodes were extracted by 3 independent reviewers. Pooled prevalences were estimated using random-effects meta-analyses.

Results: Twenty-two articles were included in qualitative review and 12 in the meta-analysis. In women with no known psychiatric illness preceding the perinatal period, pooled prevalence of BD was 2.6% (95% CI, 1.2%-4.5%) and prevalence of bipolar-spectrum mood episodes (including depressed, hypomanic/manic, mixed) during pregnancy and the postpartum period was 20.1% (95% CI, 16.0%-24.5%). In women with a prior BD diagnosis, 54.9% (95% CI, 39.2%-70.2%) were found to have at least one bipolar-spectrum mood episode occurrence in the perinatal period.

Conclusions: Our review suggests that the perinatal period is associated with high rates of bipolar-spectrum mood episodes and that pregnant and postpartum women represent a special risk population. This review may help to inform clinical care recommendations, thus helping to identify those who may have.

Suicide Among Women and the Role of Women's Health Care Providers

Importance

Suicide is a leading cause of death in the United States, with increasing rates among women. Women are more likely to experience suicidal ideation and engage in suicide behavior than men, and risk is elevated at key points where they may engage in care with a women's health care provider.

Objective

This review describes the prevalence of and risk factors for suicide among women and highlights the role of obstetrician-gynecologists in suicide prevention.

Evidence Acquisition

A PubMed, MEDLINE, and PsycINFO search was completed for English-language publications about suicide among women, including subtopics (eg, perinatal suicide, suicide during perimenopause).

Results

There are overlapping risk factors that contribute to suicide among women, including intimate partner violence and substance use. Specific groups of women may present with unique risk factors, such as women veterans, women in rural areas, and women with preexisting mental health diagnoses, particularly serious mental illnesses. Some women at risk for suicide are not seen in clinical settings, and thus community interventions may be beneficial. There are roles for obstetrician-gynecologists within and outside of the clinic to prevent suicide.

Conclusions and Relevance

Obstetrician-gynecologists can save lives by being aware of the prevalence of suicide ideation and behavior among women, understanding risk factors for suicide over the lifespan, regularly screening for these factors, asking directly about suicide ideation and intent, and being aware of clinical and community resources. Outside of the clinic, they can advocate for increased health care access and community-based interventions. These efforts can contribute to the reduction of preventable death and maternal mortality.

Postpartum depression and associated risk factors during the COVID-19 pandemic

Objective

To describe postpartum depression and associated risk factors among postpartum patients in the United States (US) between February and July 2020. This study used a cross-sectional descriptive design to collect survey data from a convenience sample of postpartum patients who lived in the US and delivered a live infant after the US declared COVID-19 a public health emergency.

Results

Our sample included 670 postpartum patients who completed an online survey inclusive of the Edinburgh Postnatal Depression Scale (EPDS) and selected demographic items (e.g. NICU admission status, infant gestational age, infant feeding method). In our sample, 1 in 3 participants screened positive for postpartum depression and 1 in 5 had major depressive symptoms. Participants who fed their infants formula had 92% greater odds of screening positive for postpartum depression and were 73% more likely to screen positive for major depressive symptoms compared to those who breastfed or bottle-fed with their own human milk. Participants with infants admitted to a NICU had 74% greater odds of screening positive. Each 1 week increase in weeks postpartum increased the odds of screening positive by 4%. Participants who worried about themselves and their infants contracting COVID-19 had 71% greater odds of screening positive.

Depression in the Postpartum Year and Life Course Economic Trajectories

INTRODUCTION

Perinatal depression affects 13% of childbearing individuals in the U.S. and has been linked to an increased risk of household economic insecurity in the short term. This study aims to assess the relationship between perinatal depression and long-term economic outcomes.

METHODS

This was a longitudinal analysis of a cohort of mothers from the Fragile Families and Child Wellbeing Study starting at delivery in 1998-2000 and followed until 2014-2017. Analysis was conducted in 2021. Maternal depression was assessed using the Composite International Diagnostic Interview-Short Form 1 year after childbirth, and the outcomes included measures of material hardship, household poverty, and employment. Associations between maternal depression and outcomes were analyzed using logistic regression and group-based trajectory modeling.

RESULTS

In total, 12.2% of the sample met the criteria for a major depressive episode 1 year after delivery. Maternal depression had a strong and sustained positive association with material hardship and not working for pay in Years 3, 5, 9, and 15 after delivery. Maternal depression also had a significant positive association with household poverty across Years 3-9 and with unemployment in Year 3. Trajectory modeling established that maternal depression was associated with an increased probability of being in a persistently high-risk trajectory for material hardship, a high-risk trajectory for household poverty, and a high-declining risk trajectory for unemployment.

CONCLUSIONS

Supporting perinatal mental health is crucial for strengthening the economic well-being of childbearing individuals and reducing the impact of maternal depression on intergenerational transmission of adversity.

Suicide and Maternal Mortality

PURPOSE OF REVIEW

Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and prevention and intervention for suicide during pregnancy and the first year postpartum.

RECENT FINDINGS

Standardization of definitions and ascertainment of maternal deaths have improved identification of perinatal deaths by suicide and risk factors for perinatal suicide. Reports of a protective effect of pregnancy and postpartum on suicide risk may be inflated. Clinicians must be vigilant for risk of suicide among their perinatal patients, especially those with mental health diagnoses or prior suicide attempts. Pregnancy and the year postpartum are a time of increased access to healthcare for many, offering many opportunities to identify and intervene for suicide risk. Universal screening for suicide as part of assessment of depression and anxiety along with improved access to mental health treatments can reduce risk of perinatal suicide.

A Humane Approach To Caring For New Mothers In Psychiatric Crisis

In England, Mother and Baby Units allow for joint inpatient admissions-the standard of care for women requiring treatment.

Trends In Primary Cesarean Section Rates Among Women With And Without Perinatal Mood And Anxiety Disorders

Reducing the rate of cesarean sections among women considered at low risk for delivery by that method is a goal of Healthy People 2030. Prior research suggests that perinatal mood and anxiety disorders increase the risk for cesarean section, but data are limited. This cross-sectional study of commercially insured women examined the relationship between perinatal depression and anxiety disorders and primary (first-time) cesarean section rates, using administrative claims data for US in-hospital deliveries from the period 2008-17. Of the 360,225 delivery hospitalizations among 317,802 unique women, 24.0 percent included a delivery by primary cesarean section, and 3.1 percent carried a diagnosis of depression, anxiety, or both made during the index pregnancy. Using an adjusted generalized estimating equation, we found that the predicted probability of primary cesarean section was 3.5 percentage points higher, on average, among women with these disorders compared with those without them. Our findings confirm the importance of pursuing research to identify mechanisms by which perinatal depression and anxiety disorders increase the risk for primary caesarean section among women otherwise considered at low risk for delivery by that method, as well as effective interventions.

Addiction treatment in the postpartum period: an opportunity for evidence-based personalized medicine

Substance use disorders (SUD) are becoming rapidly more prevalent in women and a leading cause of pregnancy associated deaths, with most deaths occurring during the 12 months after pregnancy. The postpartum period can be quite intense, especially for women seeking addiction recovery. There is a call to reconceptualize the obstetrical postpartum care model into one that extends specialised care and is tailored to an individual's specific needs. Although SUD treatment improves maternal and infant outcomes as well as decreases overdose risk, many women do not receive consistent SUD treatment during the postpartum period. Thus, SUD treatments should consider following the same guidance as obstetrics to reconceptualize how SUD treatment is delivered postpartum. Clinically, this translates into substantially modifying traditional siloed SUD treatment structures to meet the unique needs of this vulnerable patient population. At the same time, more research is urgently needed to inform these advancements in clinical care to ensure they are evidence-based and effective. In this article, we review the existing evidence as well as highlight opportunities for both clinicians and researchers to advance the integration of tailored approaches for postpartum women into personalised SUD medical and behavioural treatments.

Cultivating mental health education in obstetrics and gynecology: a call to action

Mental health disorders are common and have a significantly negative impact on the health and well-being of women. For example, perinatal mental health disorders such as anxiety and depression are widely understood to be the most common complications of pregnancy and childbirth. Untreated mental health disorders are associated with significant obstetrical and psychiatric sequelae and have a long-lasting impact on neonatal and childhood outcomes. As front-line providers for women during times of elevated risk of psychiatric morbidity, such as pregnancy and postpartum, obstetricians and gynecologists are compelled to have familiarity with such disorders. Yet, a wide gap exists between the level of education in mental health disorders that obstetrician and gynecologist providers receive and the clinical need thereof. The objectives of this commentary are to describe the urgent need for mental health education for obstetricians and gynecologists providers and to introduce our vision for a concise, evidence-based and accessible set of digital educational materials designed to convey core concepts in women's reproductive mental health.

The Collision of Mental Health, Substance Use Disorder, and Suicide

Suicide is the 10th leading cause of death, and, in women, nearly half of all suicide deaths occur during their reproductive years. Suicide is associated with psychiatric illness, especially mood and anxiety disorders. Childhood adversities, such as physical, emotional, and sexual abuse, and intimate partner violence increase the risk of suicide. Having more than one psychiatric disorder or comorbid substance use disorder also increases the risk of suicide. Substance use disorders can be the triggering factor for a suicide attempt among those who have a psychiatric condition and suicidal thoughts. Women attempt suicide three times more often than men, although they are less likely to complete suicide. Although the rate of suicide decreases in the perinatal period, pregnant women are more likely to use violent means. Women who complete suicide in the perinatal period are also more likely to be younger, married, and experiencing a depressive episode. For many women, the only encounter with the medical system they have might be in reproductive health care clinics. This means that their obstetrician-gynecologist has a unique opportunity to address women's mental health and enhance suicide prevention. The American College of Obstetricians and Gynecologists recommends screening for depression among perinatal women. Clinicians need to be aware that women with severe perinatal depression are at increased risk of suicide and that women with suicidal thoughts need careful monitoring, evaluation, and treatment.

Buprenorphine X-waiver exemption - beyond the basics for the obstetrical provider

Buprenorphine is 1 of 3 medications approved by the US Food and Drug Administration for the treatment of opioid use disorder, and practitioners must obtain a federal waiver to prescribe buprenorphine. Until recently, physicians and advanced practice clinicians were required to complete 8 and 24 hours of training, respectively, before applying for this waiver and to provide psychosocial services when prescribing buprenorphine to ≤30 patients. The US Department of Health and Human Services announced in April 2021 that eligible providers would be exempt from the educational requirement for certification, making the waiver more accessible for those intending to prescribe to ≤30 patients. Here, we reviewed the historic background to the exemption and provided practical guidelines to practitioners caring for obstetrical patients with opioid use disorder who are considering applying for the waiver for the first time. Because the educational requirements will no longer be required for X-waiver application, we reviewed fundamental topics and challenging scenarios that are often reviewed in certification courses.