A closer look at the nosological status of the highs (hypomanic symptoms) in the postpartum period

Maternal refugee status is associated with less favourable motor performance and behaviour in term infants referred to a neonatal ward: a cross-sectional study

BACKGROUND

Anxiety and depression are highly prevalent among Syrian refugees. Anxiety and depression during pregnancy may impair infant neurodevelopment. This study evaluated whether potential maternal anxiety and depression in Syrian refugee and native Turkish mothers were associated with less favourable neonatal neurodevelopment.

STUDY DESIGN

Cross-sectional study.

METHODS

Turkish (n = 64) and Syrian (n = 17) term-born infants (37-41 weeks' gestation) referred to a level II-III neonatal intensive care unit in Izmir were assessed shortly after birth (median 5 days) together with their mothers. The Test of Infant Motor Performance (TIMP) was the primary outcome measure. In addition, we evaluated crying behaviour during the TIMP-assessment and performed General Movements Assessment (GMA). Mothers completed Beck Anxiety and Beck Depression Inventories in their native languages. Univariate and multivariate statistics were applied.

RESULT

Perinatal social characteristics of both groups were similar. TIMP scores of Syrian infants were significantly lower than those of Turkish infants (45.53 (SD 7.10) vs. 51.59 (SD 8.59), respectively (p = 0.009)). Sixteen Turkish infants (25%) and ten Syrian infants (59%) had TIMP z-scores below - 1 SD (unadjusted OR = 1.27 (95%CI 1.06-1.54); adjusted OR = 1.30 (95%CI 1.05-1.61)). At TIMP-assessment's end, more Syrian infants cried (29%) compared to Turkish infants (8%; unadjusted OR 4.92 (95%CI 1.23-19.67). This association lost significance after adjustment (OR = 4.87; 95%CI 0.77-31.01). GMA ratings of both groups were similar (definitely abnormal Turkish infants (n = 5; 8%); Syrian infants (n = 1; 7%); unadjusted OR = 0.91 (95%CI 0.30-2.78); adjusted OR = 1.66 (95%CI 0.42-6.61)). Anxiety and depression scores of both mothers` groups were low (median anxiety scores of Syrian mothers 0, Turkish mothers 1; median depression scores of Syrian mothers 0, Turkish mothers 2.5). The low maternal anxiety and depression scores were not associated with the infants' TIMP scores.

CONCLUSIONS

Maternal refugee status was associated with less favourable neonatal motor performance, with about half of the Syrian refugee newborns having a TIMP score indicating the need for close monitoring of development and a potential need for early intervention. Motor performance was not associated with maternal reports of anxiety and depression. Nonetheless, the study suggests that the neurodevelopment of babies born to refugee mothers should be carefully monitored to enable early intervention whenever required.

Canadian Network for Mood and Anxiety Treatments 2024 Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety, and Related Disorders: Guide de pratique 2024 du Canadian Network for Mood and Anxiety Treatments pour le traitement des troubles de l'humeur, des troubles anxieux et des troubles connexes périnatals

BackgroundThe Canadian Network for Mood and Anxiety Treatments (CANMAT) publishes clinical practice guidelines for mood and anxiety disorders. This CANMAT guideline aims to provide comprehensive clinical guidance for the pregnancy and postpartum (perinatal) management of mood, anxiety and related disorders.MethodsCANMAT convened a core editorial group of interdisciplinary academic clinicians and persons with lived experience (PWLE), and 3 advisory panels of PWLE and perinatal health and perinatal mental health clinicians. We searched for systematic reviews of prevention and treatment interventions for perinatal depressive, bipolar, anxiety, obsessive-compulsive and post-traumatic stress disorders (January 2013-October 2023). We prioritized evidence from reviews of randomized controlled trials (RCTs), except for the perinatal safety of medications where reviews of large high-quality observational studies were prioritized due to the absence of RCT data. Targeted searches for individual studies were conducted when systematic reviews were limited or absent. Recommendations were organized by lines of treatment based on CANMAT-defined levels of evidence quality, supplemented by editorial group consensus to balance efficacy, safety, tolerability and feasibility considerations.ResultsThe guideline covers 10 clinical sections in a question-and-answer format that maps onto the patient care journey: case identification; organization and delivery of care; non-pharmacological (lifestyle, psychosocial, psychological), pharmacological, neuromodulation and complementary and alternative medicine interventions; high-risk clinical situations; and mental health of the father or co-parent. Equity, diversity and inclusion considerations are provided.ConclusionsThis guideline's detailed evidence-based recommendations provide clinicians with key information to promote the delivery of effective and safe perinatal mental healthcare. It is hoped that the guideline will serve as a valuable tool for clinicians in Canada and around the world to help optimize clinical outcomes in the area of perinatal mental health.

Occurrence of postpartum manic or mixed episodes in women with bipolar I disorder: A systematic review and meta-analysis

OBJECTIVE

Accurate information on the frequency and prevalence of manic or mixed episodes is important for therapeutic, prognostic, and safety concerns. We aimed to estimate the risk of relapse of manic and mixed episodes after delivery in women with bipolar I disorder or schizoaffective disorder-bipolar type.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search in PubMed, PsycINFO, Embase, and Cochrane databases was carried out on November 17, 2022, using the terms ((bipolar disorder) OR (manic depressive illness)) AND (mania)) AND (postpartum)) AND (recurrence)) AND (relapse). The search was updated on March 29, 2023. Case studies and qualitative analyses were excluded. Twelve studies reporting on 3595 deliveries in 2183 women were included in the quantitative analysis.

RESULTS

The overall pooled estimate of postpartum relapse risk was 39% (95% CI = 29, 49; Q(11) = 211.08, p < 0.001; I2 = 96.31%). Among those who had a relapse, the pooled estimate of risk for manic and mixed episodes was 38% (95% CI = 28, 50; Q(11) = 101.17, p < 0.001; I2 = 91.06%). Using data from the nine studies that reported the percentage of medication use during pregnancy, we estimated a meta-regression model with the percent medication use as a continuous explanatory variable. The estimated prevalence of relapse was 58.1% (95% CI, 9.6 to 39.3 to 76.8) for studies with no medication use and 25.9% (95% CI, 10.5-41.3) for studies with 100% medication use. The difference between the two prevalence estimates was statistically significant, z = -2.099, p = 0.0359.

CONCLUSIONS

Our findings suggest an overall pooled estimate of postpartum relapse risk of 39%, while the pooled estimate of risk for manic and mixed episodes was 38%. These findings highlight the need to educate patients with bipolar I disorder, and their healthcare professionals about the high risk of relapse of manic or mixed episodes after delivery.

Preventing recurrence of postpartum depression by regulating sleep

INTRODUCTION

Women are at a high risk of recurrence of depression in the postpartum period. Given the circumscribed duration of the risk period and knowledge of its triggers, postpartum depression should be easily preventable. However, prophylactic drug studies have reported contradictory findings partly due to the heterogeneity of the disorder. Currently, there are no studies on the efficacy of psychotherapy in the prevention of postpartum depression in women with major depressive or bipolar disorder.

AREAS COVERED

This review evaluates the results of controlled medication and psychotherapeutic studies in the prevention of depression in women with major depressive disorder or bipolar disorder; it further suggests that the management of sleep loss/insomnia may be an effective strategy in the prevention of postpartum depression.

EXPERT OPINION

A thorough understanding of the clinical course of the antecedent mood disorder and historical treatment response is necessary before the implementation of strategies for the prevention of postpartum depression. Targeting disturbed and/or insufficient sleep - a common and early transdiagnostic symptom of peripartum psychiatric disorders - may be a more effective intervention for the prevention of postpartum depression and psychiatric comorbidities in some individuals than the traditional approach of antidepressant use.

Postpartum Relapse in Patients with Bipolar Disorder

Pregnancy and postpartum are vital times of greater vulnerability to suffer a decompensation of bipolar disorder (BD). Methods: A systematic literature search was performed on public electronic medical databases, following PRISMA guidelines. Studies were included if they reported postpartum relapse in patients diagnosed with BD according to Diagnosis Statistical Manual (DSM) or International Classification Disease (ICD) criteria. Results: Sixteen articles describing 6064 deliveries of 3977 women were included in the quantitative analyses. The overall risk of postpartum relapse was 36.77%. The methodology of the studies, the diagnostic criteria, the discrimination between BD type I and II, and the origin of the sample were very heterogeneous. Conclusions: the rate of postpartum bipolar relapse is very high, as it is considered to be a critical period. It is especially important to detect decompensation in this period and to evaluate mood-stabilizing treatment, given the high risk of relapse concentrated in a short period.

Managing bipolar disorder during pregnancy and the postpartum period: a critical review of current practice

Introduction: Despite increased interest in the pharmacotherapy of bipolar disorder during pregnancy and the postpartum period, management of the disorder during these critical periods in a woman's life remains challenging.Areas covered: The authors review the effect of pregnancy and the postpartum period on the course of bipolar disorder, describe adverse pregnancy and birth outcomes, and discuss the pharmacotherapy of bipolar disorder during and after pregnancy.Expert opinion: When treating women with bipolar disorder of childbearing age, clinicians should consider the possibility of pregnancy. Pre-conception counseling should be an integral part of the overall plan to manage bipolar disorder during and after pregnancy. Peripartum management of bipolar disorder is challenging and requires balancing of risks associated with the use of drugs and the potentially deleterious effects of untreated bipolar disorder on the fetus/child. Formulation of personalized treatment requires knowledge of both current (episode type, symptom severity, psychiatric comorbidity, and safety concerns) and historical (episode frequency, response to drugs and psychotherapy, and the effect of reproductive events including pregnancy and postpartum period) factors. Close monitoring is essential for early detection and management of mood episodes. Routine safety assessments are necessary to identify women at risk of harming themselves or the newborn.