A psychiatric mother-baby day hospital for pregnant and postpartum women

Are virtual services equivalent for mood, anxiety, and bonding? examining a perinatal intensive outpatient program

PURPOSE

Perinatal Intensive Outpatient Programs (IOPs) address severe perinatal mood and anxiety disorders (PMADs) and mother-infant relationship concerns. Given the impact of PMADs on mothers and infants, rapid transitions to virtual services (telehealth) amid COVID-19, and service expansions to populations in need, it is critical to evaluate how effectively virtual and in-person perinatal IOP services treat PMADs and mother-infant bonding.

METHODS

This quality-improvement record review examined patient records (n = 361) for a perinatal IOP from May 2016 to July 2023, amid multiple transitions between in-person and virtual services related to COVID-19, influenza, and respiratory syncytial virus. Patients in the completed measures sample (n = 115) completed depression (EPDS), anxiety (GAD-7, PASS), and mother-infant bonding (PBQ) measures over the first 3 weeks of treatment. Patients also anonymously provided program satisfaction ratings and qualitative feedback.

RESULTS

While anxiety and depression symptoms improved similarly across service settings, mother-baby bonding only significantly improved with in-person treatment. Patient symptom outcomes also differed by public/private insurance, race, and number of children. Patients reported high service ratings and overall satisfaction, and available feedback indicates some preference for in-person services.

CONCLUSION

As perinatal mental health services and IOPs continue to expand, virtual services can similarly address anxiety and depression symptoms and help to reach in-need populations. However, for perinatal IOPs, the core treatment target of mother-infant bonding may be uniquely addressed via in-person services.

Attachment classification and early adversity predict perinatal partial hospital treatment response

BACKGROUND

Depression and anxiety are common in the perinatal period. While most of those affected respond well to treatment, a subpopulation is more resistant. Understanding more about individuals who do not respond well to available treatments may improve care for this group.

METHODS

We administered entry and exit self-report measures to 178 women who participated in a specialized partial hospitalization program for perinatal individuals. Baseline measures of anxiety, obsessive symptoms, sleep quality, early life adversity, and adult attachment security were examined as potential predictors of response to treatment.

RESULTS

While no individual baseline survey predicted treatment response, clustering patients on the basis of a combination of self-report adult attachment styles and early life adversity yielded four distinct groups. A cluster with high attachment anxiety, high attachment avoidance, and childhood history of verbal and emotional abuse was less responsive to treatment than the other groups.

CONCLUSIONS

Combining detailed information about self-report adult attachment style and early life adversity may improve prediction of treatment response in individuals with perinatal mood and anxiety disorders.

Models of care: Opportunities and challenges

Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.

Treating postpartum affective and/or anxiety disorders in a mother-baby day hospital: preliminary results

INTRODUCTION

Women experiencing perinatal mental-health illness have unique needs. The present study analyzes preliminary data about the effectiveness of MBDH in treating postpartum women with affective and anxiety disorders.

METHODS

We analysed 33 mothers with affective and/or anxiety disorders treated at the MBDH with their babies between March 2018 and December 2019. All women were assessed at admission, discharge and three months after discharge. Outcomes included symptoms of depression (EPDS) and anxiety (STAI-S), mother-infant bonding (PBQ) and functional impairment (HoNOs). We also assessed the clinical significance of changes in patients' scores on these scales and patient satisfaction.

RESULTS

At discharge, no patients still met the full criteria for the main diagnosis. Between admission and discharge, symptoms of depression and anxiety, mother-infant bonding, functional impairment and autonomy in caring for babies improved significantly. These gains were maintained at three months follow-up. Patient satisfaction was high.

CONCLUSIONS

These preliminary results suggest that multidisciplinary intervention for postpartum women with affective or anxiety disorders at the MBDH improves maternal psychopathology, mother-infant bonding and mothers' ability to care for their babies. MBDHs are a promising approach for delivering specialised perinatal mental-health care for mother-baby dyads.

Uncovering the Model and Philosophy of Care of a Psychiatric Inpatient Mother-Baby Unit in a Qualitative Study with Staff

The postnatal period is high-risk time for the first onset and recurrence of maternal mental health disorders. Untreated maternal mental illness can have significant adverse impacts on a woman, her baby, and the wider family unit. For women with mental illnesses that cannot be managed in the community, psychiatric inpatient mother-baby units are the gold standard treatment whereby mothers are co-admitted with their infant for specialist perinatal and infant mental health assessment and treatment. The study explores the model of care and examines the philosophies of care that are used within a psychiatric mother-baby unit. Purposive sampling was used to conduct semi-structured focus group and individual interviews with multidisciplinary staff members at a single mother-baby unit. Themes derived from these interviews were coded into two primary themes and a range of sub-themes. The first primary theme focused on the Model of Care consisting of the following sub-themes: mental health care, physical health care, babies' care, building mother-baby relationship, fostering relationships with supports, and facilitating community support. The second primary theme centered around the Philosophy of Care comprising of: person-centered care, trauma-informed care, compassion-centered care, recovery-oriented care, attachment-informed care, non-judgmental care, strengths-based care and interdisciplinary care. The model can be used to provide consistency across mother-baby units and to support core capabilities of staff in providing an optimal level of care.

Intensive Perinatal Mental Health Programs in the United States: A Call to Action

Despite the growth of intensive perinatal mental health programs in the United States, too few programs serve women with perinatal mood and anxiety disorders (PMADs). Furthermore, little is known about program operations, services, the women served, and the methods of collecting outcome data. With this Open Forum, the authors aimed to share their investigation of intensive perinatal mental health programs in the United States and offer recommendations to improve services for women with PMADs. The authors recommend forming a national consortium that can foster collaboration to expand existing services and establish a national database to inform program development, evaluation, policies, and funding.

Perinatal Obsessive-Compulsive Disorder: Epidemiology, Phenomenology, Etiology, and Treatment

PURPOSE OF REVIEW

We review recent evidence concerning the epidemiology, etiology, and treatment of obsessive-compulsive disorder (OCD) in the perinatal period. We examine studies reporting on rates of both new-onset OCD and exacerbation in both pregnancy and postpartum; explore both biological and psychosocial risk factors for the disorder; and review the latest evidence concerning treatment.

RECENT FINDINGS

Evidence is limited in all areas, with rates of both OCD and subthreshold obsessive-compulsive symptoms varying widely across studies. Prevalence is likely higher in the perinatal period than in the general population. Clinical features in the perinatal period are more likely than at other times to concern harm to the child, with contamination and aggressive obsessions and cleaning and checking compulsions especially common. Research into the biological etiology is too limited at this time to be definitive. Both observational and randomized controlled trials support cognitive behavioral therapy with exposure and response prevention (CBT with ERP) as a first-line treatment, with limited evidence also supporting the use of selective serotonin reuptake inhibitors (SSRIs). Treatment considerations in the perinatal period must weigh the risks of treatment vs. the risks of untreated illness. Perinatal OCD is common and can be impairing. Clinical features differ somewhat compared to non-perinatal periods. Treatment does not differ from that used in the general population, though evidence pertaining specifically to the perinatal period is sparse.

Exploring Discharge Outcomes and Readmission Rates of Mothers Admitted to a Psychiatric Mother and Baby Unit

To evaluate change in Health of the Nation Outcome Scale (HoNOS) scores from admission to discharge, readmission rates after 28-day and six months post-discharge, and factors associated with readmission in a Mother and Baby Unit (MBU). An exploratory cohort study was completed of mother-infant dyads admitted to a public psychiatric MBU in Australia between March 2017 and August 2018 (18 months). Admission and discharge scores on the clinician-rated Health of the Nation Outcome Scale (HoNOS) were compared using dependent samples t-tests. The frequency of readmission to any psychiatric inpatient unit within six months of discharge was determined from medical records. Characteristics of mothers who were and were not readmitted were evaluated. Of the 82 mother-infant dyads admissions, 12 (14.63%) women were readmitted within six months, and six (7.31%) were readmitted within 28-days. Total HoNOS scores significantly improved between admission and discharge (t₍₈₁₎=9.45, p<.000). Descriptive statistics for demographics, diagnoses, Mental Health Act status and discharge supports were computed for women readmitted and not readmitted. While these readmission rates and HONOS scores reflect a successful MBU admission, further research is required with larger sample sizes and more specific maternal and infant mental health outcome measures.

Father's Perspectives on Family Relationships and Mental Health Treatment Participation in the Context of Maternal Postpartum Depression

Objective: To understand the perspectives of fathers whose partners experienced postpartum depression, particularly (1) views on how fathers and family relationships were impacted by maternal PPD, and (2) attitudes regarding inclusion of fathers within the treatment process. Methods: We conducted qualitative interviews with 8 postpartum couples using a semi-structured protocol, and administered questionnaires assessing demographics, depression, and family functioning. We abstracted data from hospital records regarding the mother's depressive episode. We summarized quantitative data using descriptive statistics, and analyzed interview transcripts using qualitative analysis techniques, focusing specifically on fathers' input on postpartum relationships and treatment involvement. Results: Over one-third of fathers had elevated symptoms of depression, and family functioning scores suggested that most couples were experiencing dysfunction in their relationships. Qualitative analysis identified three major categories of themes, and subthemes in each category. Major themes included: (1) fathers' experiences during the postpartum period, including not understanding postpartum mental health conditions and desiring more information, experiencing a range of emotions, and difficulty of balancing work with family; (2) fathers' views on postpartum relationships, such as communication problems, empathy for partner, and relationship issues with other family members; (3) fathers' attitudes toward postpartum treatment, including openness to be involved, perceived benefits, and barriers and facilitators to the inclusion of partners in treatment. Conclusion: Though barriers exist, many fathers are motivated to be included in the treatment process. In addition to supporting maternal wellbeing, fathers view treatment as a means to improve issues in the couple or family system, such as communication difficulties.

Keeping Parent, Child, and Relationship in Mind: Clinical Effectiveness of a Trauma-informed, Multigenerational, Attachment-Based, Mother-Baby Partial Hospital Program in an Urban Safety Net Hospital

PURPOSE

The Hennepin Healthcare Mother-Baby Day Hospital is a partial hospital program for pregnant and postpartum women with moderate to severe psychiatric illness. Based in an urban safety net hospital, the Day Hospital provides trauma-informed, multigenerational, group-based therapy and psychiatric care. This report describes the program and preliminary data regarding maternal mental health and functioning at treatment entry and discharge.

METHODS

Data include information on pregnant and postpartum women who were admitted to the Day Hospital between April 2013 and September 2019 and completed at least 4 days of treatment. We describe patient demographics and changes in mental health and maternal functioning.

RESULTS

328 women consented to participation in research, representing 364 unique admissions. Primary diagnoses included major depression (55.6%; n = 202); generalized anxiety (36.4%; n = 132); bipolar spectrum (28%; n = 102); and trauma-related disorders (20.6%; n = 75). Patients reported significant improvements (p < 0.001) in self-report scales assessing depression, anxiety, and maternal functioning.

CONCLUSIONS

A mother-baby day hospital based in an urban safety net hospital is effective in improving mental health and parenting functioning in perinatal women with moderate to severe psychiatric illness. The high acuity and prevalence of comorbid depression, anxiety, bipolar spectrum, and trauma-related disorders support the need for trauma-informed, multigenerational approaches that address perinatal mental health and attachment-based parenting support.

Postpartum Maternal Tethering: A Bioethics of Early Motherhood

This article proposes a new way of conceptualizing the ethical relationship between postpartum mothers and their newborn babies. I suggest that the intertwinement of mother and baby - and the tensions that this intertwinement produces - do not disappear with birth, but rather persist throughout the postpartum period in the form of postpartum maternal tethering. I draw upon three years of ethnographic fieldwork and training in the US and China to argue that the dependency associated with postpartum maternal tethering makes it extremely difficult for postpartum mothers to act autonomously, even in the relational sense. I then examine how breaches in the postpartum maternal tether can open up new possibilities for thinking about the bioethics of vulnerability, dependency and care, by denaturalizing and de-sanctifying the mother-baby relationship and diversifying newborn care.

When the Ghosts Live in the Nursery: Postpartum Depression and the Grandmother-Mother-Baby Triad in Luzhou, China

In Luzhou, China, where grandmothers often serve as primary caregivers for infants, the past and the future haunt new mothers suffering from postpartum depression. In this article, I draw upon longitudinal interviews conducted with ten families in Luzhou as part of a larger multi-sited ethnography of postpartum depression and anxiety. I argue that the grandmother-mother-baby triad model of infant care in interior urban China accentuates the pain of depressed postpartum mothers by making it difficult for them to rid their homes of the ghosts of past trauma and lost futures. Mothers resent and fear grandmothers even as they rely on them to care for their babies. Memories of trauma, perceived displacement by the grandmother as the mother figure for their babies, and lack of control over their households and children characterize postpartum mothers' experiences. Mothers primarily blame their mothers-in-law for their unhappiness even as they depend on themselves to "self-adjust."

Inpatient mother-and-child postpartum psychiatric care: Factors associated with improvement in maternal mental health

Purpose

This study assessed the underexplored factors associated with significant improvement in mothers’ mental health during postpartum inpatient psychiatric care.

Methods

This study analyzed clinical improvement in a prospective cohort of 869 women jointly admitted with their infant to 13 psychiatric Mother-Baby Units (MBUs) in France between 2001 and 2007. Predictive variables tested were: maternal mental illness (ICD-10), sociodemographic characteristics, mental illness and childhood abuse history, acute or chronic disorder, pregnancy and birth data, characteristics and mental health of the mother's partner, and MBU characteristics.

Results

Two thirds of the women improved significantly by discharge. Admission for 25% was for a first acute episode very early after childbirth. Independent factors associated with marked improvement at discharge were bipolar or depressive disorder, a first acute episode or relapse of such an episode. Schizophrenia, a personality disorder, and poor social integration (as measured by occupational status) were all related to poor clinical outcomes.

Discussion

Most women improved significantly while under care in MBUs. Our results emphasize the importance of the type of disease but also its chronicity and the social integration when providing postpartum psychiatric care.

Management of perinatal depression with non-drug interventions

Perinatal depression is a common disorder that has been associated with serious risks to mother and child. Recently, screening for depression in pregnant and postpartum women has increased, as has the development of new psychotherapy and non-drug treatment modalities. Matching patients to treatments can be challenging, and although research into personalized treatment of major depression in the general population has increased, no published guidelines focus on personalized treatment approaches to perinatal depression. In particular, guidelines on non-drug treatments are lacking. This review summarizes the evidence on personalized non-drug treatment of perinatal depression, how to incorporate patients' preferences, novel treatments under investigation, and the potential role of biomarkers in matching patients to treatment. The review provides recommendations for future research in personalized care of perinatal depression.

Introducing Mother Baby Connections: a model of intensive perinatal mental health outpatient programming

Perinatal mental health problems, experienced by 15-20% of women, are a significant public health issue associated with adverse effects among childbearing women; yet only 20-25% receive adequate treatment. There has been a recent proliferation of intensive perinatal day treatment programs in the United States. To meet this need in the greater Philadelphia area, we introduce Mother Baby Connections (MBC), an innovative interdisciplinary, attachment-focused, intensive, outpatient perinatal mental health program recently launched at Drexel University. The purpose of this paper is to (1) present an overview of MBC, its theoretical framework for services, and its evidence-based components, highlighting the unique factors that differentiate this program from traditional outpatient treatment, and (2) present clinical outcome data utilizing scores from reliable and valid scales, including enrollment to discharge outcomes from 20 months of MBC operation. In sum, outcomes for 20 predominantly minority women with complete measures showed significant improvements in maternal depression symptom severity, maternal functioning, birth trauma symptoms, perceived stress, parenting stress, and emotional regulation. Effect sizes were medium to large (i.e., 0.42-2.00). We conclude that MBC is a viable model for tailored intensive outpatient treatment to foster maternal mental health and functioning during the perinatal period.

Short stay vs long stay postpartum psychiatric admissions: a population-based study

About 1-2/1000 of postpartum women require psychiatric admission. Length of stay is variable, and little is known about short postpartum admission. From all women in Ontario, Canada, with a psychiatric admission within 1 year postpartum (2007-2012) (n = 1702), we compared women with admissions <72 h to women with longer admissions on sociodemographics, clinical characteristics and post-discharge mental health service use. About 37% of admissions were <72 h. These women were more likely to be adolescents (11.7 vs 7.3%), less likely to be employed (16.6 vs 25.9%) compared to women with longer admissions, and fewer had a prior history of psychiatric admission (16.7 vs 59.0%). Index diagnoses of alcohol or substance use (12.5 vs 7.8%) and adjustment disorders (15.8 vs 6.3%) were more common in the short vs longer stay group; psychotic (5.8 vs 19.5%) and bipolar disorders (2.1 vs 14.2%) were less common. Women with short admission were at higher crude risk for ED revisit 7 days post-discharge (11.4 vs 4.9% OR2.52, 95% CI1.74-3.66) and at lower adjusted risk for readmission at 365 days post-discharge (19.5 vs 28.8%, aOR 0.63, 95% CI 0.46-0.85). Women with short stay postpartum admissions are a clinically distinct group that may benefit from targeted intervention.

Cross-Cultural Approach of Postpartum Depression: Manifestation, Practices Applied, Risk Factors and Therapeutic Interventions

It is a well known fact that postpartum depression (PPD) is a global phenomenon that women may experience, regardless of cultural identity and beliefs. This literature review presents the cultural beliefs and postnatal practices around the world, in each continent and people's origins, looking through the extent to which they contribute positively or negatively to the onset of the disease. 106 articles were used in this research, through a systematic electronic search of Pubmed (Medline) and Scopus. Comparison is also made between the prevalence, the risk factors and the different ways of appearance of the disease around the world and among immigrants. Finally, the initiatives and interventions made so far by the governments and institutions with a view to prevent and address this global problem are presented. The results showed (a) that different cultures share the same risk factors towards the disease (b) significant differences in the prevalence of the disease among both Western and non Western cultures and between the cultures themselves (c) more tendencies for somatization of depressive symptoms in non-Western cultures, (d) different postnatal practices between cultures, which are not always effective (e) the more non-West a culture is, the less interventions concern on mental health; the same phenomenon is observed on populations burdened by immigration. The beliefs held by culture should be taken seriously in detecting of PPD, as well as the assessment of the needs of women who have recently given birth.

Pedagogical Implications of Partnerships Between Psychiatry and Obstetrics-Gynecology in Caring for Patients with Major Mental Disorders

OBJECTIVE

Because there are no formal reviews, the authors set out to identify and describe programs that serve female patients with major mental disorders by integrating mental health care with services in obstetrics and gynecology and to describe the pedagogical implications of those programs.

METHOD

The authors searched PubMed for all articles describing a program in which psychiatry was formally integrated with obstetric or gynecological services, other than standard consultation-liaison programs, in the care of patients with major mental disorders. The search terms used included interdisciplinary, interprofessional, integrated, collaborative care, psychiatry, and obstetrics-gynecology or psychosomatic obstetrics-gynecology.

RESULTS

The authors found six distinct integrated programs. These included family planning clinics that were integrated into inpatient psychiatry services; inpatient and outpatient psychiatry services for pregnant mentally ill women in close collaboration with obstetric services; a day hospital for pregnant women with psychiatric disorders in an obstetric setting; an interdisciplinary training site providing care for predominantly depressed, low-income, and minority women; a primary care HIV service for women integrated with departments of obstetrics-gynecology and psychiatry; and an obstetrics-gynecology clinic-based collaborative depression care intervention for socially disadvantaged women. Residents' involvement was described in four of the programs.

CONCLUSIONS

These innovative and integrated programs potentially enhance the care of vulnerable and culturally diverse women with major mental disorders. The authors discuss how these programs may contribute to the education of residents in psychiatry and obstetrics-gynecology.

Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit

Women experiencing severe perinatal mental illness during pregnancy or postpartum have unique needs when psychiatric hospitalization is indicated. Although many countries have established mother-baby psychiatric units, similar facilities have not been available in the US. In 2011, the University of North Carolina at Chapel Hill inaugurated the first Perinatal Psychiatry Inpatient Unit in the US. We describe the unique characteristics of the patient population and report clinical outcomes guiding development and refinement of treatment protocols. Ninety-two perinatal patients were admitted between September 2011 and September 2012, and 91 completed self-report measures at admission and discharge. Perinatal unipolar mood disorder was the most frequent primary diagnosis (60.43 %), and 11 patients (12 %) were admitted with psychosis. The data document clinically and statistically significant improvements in symptoms of depression, anxiety, and active suicidal ideation between admission and discharge (p < 0.0001), as assessed by the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire, and Generalized Anxiety Disorder Scale. Overall functioning was also improved, demonstrated by a significant mean difference of -10.96 in total scores of the Work and Social Adjustment Scale (p < 0.0001). Data suggest that delivering specialized and targeted interventions for severe maternal mental illness in a safe and supportive setting produces positive patient outcomes.

Clinical correlates of perinatal bipolar disorder in an interdisciplinary obstetrical hospital setting

BACKGROUND

Pregnancy and the postpartum period can be destabilizing for women with bipolar disorder (BD), and treatment decisions particularly complex. Yet, to date, relatively little research has focused on perinatal BD.

METHOD

Following IRB approval, trained raters reviewed clinical records of 334 women who had sought treatment at a specialized partial hospitalization program serving perinatal women, including demographic, clinical, and treatment history information as noted in each patient׳s chart by treating providers.

RESULTS

Slightly over 10% of the perinatal sample was diagnosed with Bipolar I, Bipolar II, or Bipolar NOS Disorder. In addition, 26% of the sample, regardless of diagnostic status, reported recent, abnormally elevated mood persisting 4 or more days. Compared to women with other Axis I disorders, women with a BD diagnosis were more likely to report a substance abuse history, prior suicide attempts, and more extensive psychiatric histories, including greater use of pharmacotherapy. Pregnant women with BD were more likely to take psychotropic medications prenatally, and postpartum women with BD reported higher rates of birth complications and difficulty breastfeeding.

LIMITATIONS

This research is limited by use of retrospective data, and utilization of self-report and clinician diagnosis, rather than structured interviews.

CONCLUSION

Even in the context of a partial hospital sample with high levels of symptoms and impairment, the clinical features of perinatal women with BD stand out as markedly more severe in comparison to those of women seeking care for other perinatal psychiatric conditions. Risk for suicide, substance abuse, and difficulties in the mother-child relationship are concerns.

Symptoms of the anxiety disorders in a perinatal psychiatric sample: a chart review

Symptoms of anxiety are a central feature of perinatal mental health, yet the anxiety disorders have received considerably less attention than depression in both perinatal research and practice. The present investigation involved a retrospective review of the clinical records of 334 patients seen at a psychiatric day hospital program serving pregnant and postpartum women. We examined the frequency with which the patients in this setting reported symptoms of anxiety, clinical correlates of elevated anxiety, and patterns of diagnosis in the clinical record. The results suggest that anxiety symptoms are very common in this population and that the presence of anxiety is associated with a more severe clinical profile, including higher rates of suicidality and increased use of psychotropic medications during pregnancy and postpartum. Although anxiety symptom levels were markedly elevated in this sample, anxiety disorders were diagnosed at relatively low rates. Implications for clinical practice, including discharge and treatment planning, are discussed.

A mother-baby psychiatric day hospital: History, rationale, and why perinatal mental health is important for obstetric medicine

BACKGROUND

Women frequently experience depression, anxiety, or other mental health concerns during pregnancy and postpartum, impacting her and her infant's health. Patients who require management of medical conditions during the perinatal period are even more likely to experience depression and anxiety compared to those without comorbid medical issues. Despite the availability of effective treatments, perinatal mental health utilization rates are strikingly low.

METHODS

To address common treatment barriers, we developed a specialized mother-baby day hospital for women with psychiatric distress during the peripartum. In this report, we summarize findings from 800 patient satisfaction surveys collected from women treated at the program between 2007 and 2012.

RESULTS

Findings suggest that women are highly satisfied with the treatment received, often noting that the inclusion of the baby in their treatment is a highly valued feature of care.

CONCLUSION

The relevance of perinatal mental health services for patients who are followed by obstetrical medicine specialists is discussed.

Pregnancy in the severely mentally ill patient as an opportunity for global coordination of care

Although obstetricians commonly care for pregnant patients with psychiatric disorders, little has been written about the implications of managing a pregnancy during a prolonged psychiatric hospitalization for severe mental illness. Multidisciplinary care may optimize obstetric and psychiatric outcomes. We describe a severely mentally ill patient at 27 weeks' gestation (G1P0) who was admitted after a suicide attempt. She exhibited intermittently worsening depression and anxiety throughout a 2-month inpatient psychiatric hospitalization, during which her psychiatric and obstetric providers collaborated regarding her care. We review recommendations for antepartum and intrapartum treatment of the acutely suicidal and severely mentally ill patient and, in particular, the evidence that a multidisciplinary coordinated approach to planning can maximize patient physical and mental health and facilitate preparedness for delivery.

Perinatal antidepressant use: understanding women's preferences and concerns

Perinatal depression is prevalent and linked with a host of adverse consequences for women and newborns. Rates of engagement in depression treatment are, however, strikingly low among pregnant and postpartum women, with the majority of affected women receiving no mental health treatment. Research indicates that perinatal women are extremely reluctant to take antidepressant medications, yet the nature of women's concerns and treatment decision- making patterns have not been well documented. Developing a clearer understanding of women's treatment preferences and behaviors may help identify solutions to the under-treatment of perinatal depression. In this mixed methods study, we conducted in-depth interviews with 61 pregnant women, approximately half of whom were experiencing clinical levels of depression. In addition to assessing psychiatric diagnoses, symptoms, and functional impairment, we conducted qualitative interviews addressing women's preferences for depression treatment, concerns, and decision-making patterns. Consistent with prior reports, women were significantly more likely to voice a preference for non-pharmacologic depression treatments, as opposed to antidepressant medications. Many depressed women reported a great degree of uncertainty regarding how to treat their depression, and those with more severe depression symptoms were more likely to endorse decisional conflict. Analysis of qualitative comments yielded detailed information about the nature of women's concerns and preferences related to use of antidepressant medications and other aspects of treatment engagement. We discuss findings in the context of improving patient-centered care for perinatal depression.

Treatment - mother-infant inpatient units

Infants of parents with psychiatric disorders may be particularly vulnerable and have a higher risk of developing psychiatric disorders in adulthood. Until the second half of the 20th century, women and infants were cared for separately. Today, hospitalisation of women with their babies in psychiatric mother-baby units enables psychiatric care of women and promotion of parent-infant interactions and child development. The distribution of psychiatric mother-baby units around the world, as well as within countries, varies strongly. Reasons for this may be related to the absence of national perinatal mental health policies related to psychiatric mother-baby unit location, differences in sources of referral for admission, and criteria for psychiatric mother-baby unit admission. Two principal national epidemiologic studies, in England and in France and Belgium, have described issues related to discharge from such care, as have smaller local studies, but no epidemiologic studies have yet demonstrated that joint inpatient psychiatric mother-baby unit care is cost-effective compared with separate care.

Effects of cognitive therapy versus interpersonal psychotherapy in patients with major depressive disorder: a systematic review of randomized clinical trials with meta-analyses and trial sequential analyses

BACKGROUND

Major depressive disorder afflicts an estimated 17% of individuals during their lifetime at tremendous suffering and cost. Cognitive therapy and interpersonal psychotherapy are treatment options, but their effects have only been limitedly compared in systematic reviews.

METHOD

Using Cochrane systematic review methodology we compared the benefits and harm of cognitive therapy versus interpersonal psychotherapy for major depressive disorder. Trials were identified by searching the Cochrane Library's CENTRAL, Medline via PubMed, EMBASE, Psychlit, PsycInfo, and Science Citation Index Expanded until February 2010. Continuous outcome measures were assessed by mean difference and dichotomous outcomes by odds ratio. We conducted trial sequential analysis to control for random errors.

RESULTS

We included seven trials randomizing 741 participants. All trials had high risk of bias. Meta-analysis of the four trials reporting data at cessation of treatment on the Hamilton Rating Scale for Depression showed no significant difference between the two interventions [mean difference -1.02, 95% confidence interval (CI) -2.35 to 0.32]. Meta-analysis of the five trials reporting data at cessation of treatment on the Beck Depression Inventory showed comparable results (mean difference -1.29, 95% CI -2.73 to 0.14). Trial sequential analysis indicated that more data are needed to definitively settle the question of a differential effect. None of the included trial reported on adverse events.

CONCLUSIONS

Randomized trials with low risk of bias and low risk of random errors are needed, although the effects of cognitive therapy and interpersonal psychotherapy do not seem to differ significantly regarding depressive symptoms. Future trials should report on adverse events.

The effect of adding psychodynamic therapy to antidepressants in patients with major depressive disorder. A systematic review of randomized clinical trials with meta-analyses and trial sequential analyses

BACKGROUND

Major depressive disorder afflicts an estimated 17% of individuals during their lifetimes at tremendous suffering and costs. Psychodynamic therapy may be a treatment option for depression, but the effects have only been limitedly assessed in systematic reviews.

METHOD

Using Cochrane systematic review methodology, we compared the benefits and harms of psychodynamic therapy versus 'no intervention' or sham for major depressive disorder. We accepted any co-intervention, including antidepressants, as long as it was delivered similarly in both intervention groups. Trials were identified by searching the Cochrane Library's CENTRAL, MEDLINE via PubMed, EMBASE, Psychlit, Psyc Info, and Science Citation Index Expanded until February 2010. Two authors independently extracted data. We evaluated risk of bias to control for systematic errors. We conducted trial sequential analysis to control for random errors.

RESULTS

We included five trials randomizing a total of 365 participants who all received antidepressants as co-intervention. All trials had high risk of bias. Four trials assessed 'interpersonal psychotherapy' and one trial 'short psychodynamic supportive psychotherapy'. Meta-analysis showed that psychodynamic therapy significantly reduced depressive symptoms on the 17-item Hamilton Rating Scale for Depression (mean difference -3.01 (95% confidence interval -3.98 to -2.03; P<0.00001), no significant heterogeneity between trials) compared with 'no intervention'. Trial sequential analysis confirmed this result.

LIMITATIONS

Our results are based on few trials with high risk of bias and a limited number of participants so our results may be questionable.

CONCLUSIONS

Adding psychodynamic therapy to antidepressants might benefit depressed patients, but the possible treatment effect measured on the Hamilton Rating Scale for Depression is small.

The effects of cognitive therapy versus 'treatment as usual' in patients with major depressive disorder

BACKGROUND

Major depressive disorder afflicts an estimated 17% of individuals during their lifetimes at tremendous suffering and costs. Cognitive therapy may be an effective treatment option for major depressive disorder, but the effects have only had limited assessment in systematic reviews.

METHODS/PRINCIPAL FINDINGS

Cochrane systematic review methodology, with meta-analyses and trial sequential analyses of randomized trials, are comparing the effects of cognitive therapy versus 'treatment as usual' for major depressive disorder. To be included the participants had to be older than 17 years with a primary diagnosis of major depressive disorder. Altogether, we included eight trials randomizing a total of 719 participants. All eight trials had high risk of bias. Four trials reported data on the 17-item Hamilton Rating Scale for Depression and four trials reported data on the Beck Depression Inventory. Meta-analysis on the data from the Hamilton Rating Scale for Depression showed that cognitive therapy compared with 'treatment as usual' significantly reduced depressive symptoms (mean difference -2.15 (95% confidence interval -3.70 to -0.60; P<0.007, no heterogeneity)). However, meta-analysis with both fixed-effect and random-effects model on the data from the Beck Depression Inventory (mean difference with both models -1.57 (95% CL -4.30 to 1.16; P = 0.26, I(2) = 0) could not confirm the Hamilton Rating Scale for Depression results. Furthermore, trial sequential analysis on both the data from Hamilton Rating Scale for Depression and Becks Depression Inventory showed that insufficient data have been obtained.

DISCUSSION

Cognitive therapy might not be an effective treatment for major depressive disorder compared with 'treatment as usual'. The possible treatment effect measured on the Hamilton Rating Scale for Depression is relatively small. More randomized trials with low risk of bias, increased sample sizes, and broader more clinically relevant outcomes are needed.

The effect of interpersonal psychotherapy and other psychodynamic therapies versus 'treatment as usual' in patients with major depressive disorder

BACKGROUND

Major depressive disorder afflicts an estimated 17% of individuals during their lifetimes at tremendous suffering and costs. Interpersonal psychotherapy and other psychodynamic therapies may be effective interventions for major depressive disorder, but the effects have only had limited assessment in systematic reviews.

METHODS/PRINCIPAL FINDINGS

Cochrane systematic review methodology with meta-analysis and trial sequential analysis of randomized trials comparing the effect of psychodynamic therapies versus 'treatment as usual' for major depressive disorder. To be included the participants had to be older than 17 years with a primary diagnosis of major depressive disorder. Altogether, we included six trials randomizing a total of 648 participants. Five trials assessed 'interpersonal psychotherapy' and only one trial assessed 'psychodynamic psychotherapy'. All six trials had high risk of bias. Meta-analysis on all six trials showed that the psychodynamic interventions significantly reduced depressive symptoms on the 17-item Hamilton Rating Scale for Depression (mean difference -3.12 (95% confidence interval -4.39 to -1.86;P<0.00001), no heterogeneity) compared with 'treatment as usual'. Trial sequential analysis confirmed this result.

DISCUSSION

We did not find convincing evidence supporting or refuting the effect of interpersonal psychotherapy or psychodynamic therapy compared with 'treatment as usual' for patients with major depressive disorder. The potential beneficial effect seems small and effects on major outcomes are unknown. Randomized trials with low risk of systematic errors and low risk of random errors are needed.

Postpartum depression

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.

Consumers' views on the use of diagnostic labels to describe psychological distress in the postpartum: implications for health care

Postpartum psychological distress is common and its detection is important in primary health care. Australia’s residential early parenting centres admit mothers with their infants and treat both infant sleep and settling and maternal mental health. Many women have health problems but low uptake of professional assistance after discharge. Psychological distress may be conceptualised as either individual psychopathology or a normal reaction to caring for an unsettled infant, loss of identity and status, and limited emotional and practical assistance, but the potential benefits or harms of psychiatric labelling are uncertain. We examined the opinions of consumers of a residential early parenting centre. The method used was that, 12 months after discharge, a self-report survey was mailed. Results showed 50/94 (54%) women returned completed surveys. Participants identified perceived causes of postpartum psychological distress as: difficult infant temperament and behaviour (57%); fatigue (53%); and insufficient support (47%). Sixty-one per cent thought that diagnostic labels could improve access to health care, but 58% believed that it might cause others to question a woman’s mothering ability or limit access to employment (83%). Psychiatric labels may improve access to health care in the postpartum, but effective treatments will address causes of distress as understood by women.

Psychiatric disorders in pregnant and postpartum women in the United States

CONTEXT

Psychiatric disorders and substance use during pregnancy are associated with adverse outcomes for mothers and their offspring. Information about the epidemiology of these conditions in this population is lacking.

OBJECTIVE

To examine sociodemographic correlates, rates of DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking among past-year pregnant and postpartum women in the United States.

DESIGN

National survey.

SETTING

Face-to-face interviews conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions.

PARTICIPANTS

A total of 43 093 respondents were interviewed, of whom 14 549 were women 18 to 50 years old with known past-year pregnancy status.

MAIN OUTCOME MEASURES

Prevalence of 12-month DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking.

RESULTS

Past-year pregnant and postpartum women had significantly lower rates of alcohol use disorders and any substance use, except illicit drug use, than nonpregnant women. In addition, currently pregnant women had a lower risk of having any mood disorder than nonpregnant women. The only exception was the significantly higher prevalence of major depressive disorder in postpartum than in nonpregnant women. Age, marital status, health status, stressful life events, and history of traumatic experiences were all significantly associated with higher risk of psychiatric disorders in pregnant and postpartum women. Lifetime and past-year treatment-seeking rates for any psychiatric disorder were significantly lower among past-year pregnant than nonpregnant women with psychiatric disorders. Most women with a current psychiatric disorder did not receive any mental health care in the 12 months prior to the survey regardless of pregnancy status.

CONCLUSIONS

Pregnancy per se is not associated with increased risk of the most prevalent mental disorders, although the risk of major depressive disorder may be increased during the postpartum period. Groups of pregnant women with particularly high prevalence of psychiatric disorders were identified. Low rates of maternal mental health care underscore the need to improve recognition and delivery of treatment for mental disorders occurring during pregnancy and the postpartum period.