Thyroid and adrenal measures during late pregnancy and the puerperium in women who have been major depressed or who become dysphoric postpartum

Postpartum symptoms of anxiety, depression and stress: differential relationships to women's cortisol profiles

PURPOSE

Women are at high risk of stress, anxiety, and depression during the postpartum but the ways in which these different types of psychological distress are related to cortisol regulation is not clear. We examined the distinct association of each type of distress with women's average cortisol level, cortisol awakening response (CAR), cortisol decline across the day (diurnal slope), and overall amount of cortisol secretion across the day (AUCG).

METHODS

At 6 months postpartum, a diverse group of 58 women completed measures of depression, anxiety, perceived stress, and life stressors. Each woman provided 4 salivary samples for cortisol assay from waking to bedtime on each of 2 consecutive days. Linear regressions were used to examine associations of stress, anxiety and depression to each of the 4 cortisol measures, controlling for number of stressful life events.

RESULTS

Depressive symptoms were associated with less of a rise in the CAR (β = -.46, p = 0.01), steeper diurnal slope (β = .51, p = 0.006), and higher average cortisol level (β = .42, p = .01). Women who met the clinical cutoff for an anxiety disorder had lower overall cortisol output (β = -.29, p = 0.03). Stress was not related to any cortisol metric.

CONCLUSIONS

Findings suggest that stress is less associated with cortisol alterations in the postpartum than are more severe types of psychological distress. Anxiety and depression may have distinct and opposite profiles of cortisol dysregulation. Results indicate that mental health assessment is critical even in the later postpartum so that interventions can be initiated to reduce emotional suffering and the risk of impaired cortisol regulation.

The role of stress in perinatal depression and anxiety - A systematic review

Perinatal depression (PND) and anxiety affect around 20% of women, but available pharmacotherapy is not sufficiently effective in 20-60% of them, indicating a need for better understanding of these diseases. Since stress is a significant risk factor for PND, the aim was to examine the role of biological, environmental and psychological stress in PND and anxiety through a systematic literature search. Overall 210 studies were included, among which numerous rodent studies showed that perinatal stress induced depressive-like and anxious behavior, which was associated with HPA-axis alterations and morphological brain changes. Human studies indicated that the relationship between cortisol and perinatal depression/anxiety was not as clear and with many contradictions, although social and psychological stress were clearly positively associated with PND. Finally, oxytocin, synthetic neuroactive steroid and n-3 PUFA diet have been identified as potentially beneficial in the therapy of PND and anxiety, worth to be investigated in the future.

The role of the hypothalamic-pituitary-adrenal axis in depression across the female reproductive lifecycle: current knowledge and future directions

The aim of this narrative review is to consolidate knowledge on the role of the hypothalamic-pituitary-adrenal (HPA) axis in depression pathophysiology at different reproductive stages across the female lifespan. Despite growing evidence about the impact of gonadal hormones on mood disorders, no previous review has examined the interaction between such hormonal changes and the HPA axis within the context of depressive disorders in women. We will focus on HPA axis function in depressive disorders at different reproductive stages including the menstrual cycle (e.g., premenstrual dysphoric disorder [PMDD]), perinatally (e.g., postpartum depression), and in perimenopausal depression. Each of these reproductive stages is characterized by vast physiological changes and presents major neuroendocrine reorganization. The HPA axis is one of the main targets of such functional alterations, and with its key role in stress response, it is an etiological factor in vulnerable windows for depression across the female lifespan. We begin with an overview of the HPA axis and a brief summary of techniques for measuring HPA axis parameters. We then describe the hormonal milieu of each of these key reproductive stages, and integrate information about HPA axis function in depression across these reproductive stages, describing similarities and differences. The role of a history of stress and trauma exposure as a contributor to female depression in the context of HPA axis involvement across the reproductive stages is also presented. This review advances the pursuit of understanding common biological mechanisms across depressive disorders among women. Our overarching goal is to identify unmet needs in characterizing stress-related markers of depression in women in the context of hormonal changes across the lifespan, and to support future research in women's mental health as it pertains to pathophysiology, early diagnosis, and treatment targets.

Hair Cortisol Concentration as a Biomarker of Symptoms of Depression in the Perinatal Period

Pregnancy is a sensitive period when women experience major hormonal and psychological changes. A high prevalence of the symptoms of depression and manifested major depression rates have been reported during this period, leading to negative outcomes both for mothers and the offspring. Despite its prevalence, the aetiology of depression is not yet fully understood. Nonetheless, alterations in cortisol levels have been proposed as a reliable biomarker to identify pregnant women at risk of perinatal depression. Hair cortisol has recently been extensively used in bio-psychological studies as a suitable non-invasive biomarker for several neuropsychiatric disorders. Various studies have published evidence regarding the relationship between cortisol fluctuations during the perinatal period, measured both in hair and in other substrates, and the onset of perinatal symptoms of depression. This current review provides an overview of cortisol level changes measured in women's hair during pregnancy or the postpartum period and its association with perinatal symptoms of depression. Further studies, including repetitive measurement of both hair cortisol and depression throughout the prenatal period, must be performed to clarify the relationship between cortisol levels and perinatal symptoms of depression.

Targeting the Arginine Vasopressin V1b Receptor System and Stress Response in Depression and Other Neuropsychiatric Disorders

A healthy stress response is critical for good mental and overall health and promotes neuronal growth and adaptation, but the intricately balanced biological mechanisms that facilitate a stress response can also result in predisposition to disease when that equilibrium is disrupted. The hypothalamic-pituitary-adrenal (HPA) axis neuroendocrine system plays a critical role in the body's response and adaptation to stress, and vasopressinergic regulation of the HPA axis is critical to maintaining system responsiveness during chronic stress. However, exposure to repeated or excessive physical or emotional stress or trauma can shift the body's stress response equilibrium to a "new normal" underpinned by enduring changes in HPA axis function. Exposure to early life stress due to adverse childhood experiences can also lead to lasting neurobiological changes, including in HPA axis function. HPA axis impairment in patients with depression is considered among the most reliable findings in biological psychiatry, and chronic stress has been shown to play a major role in the pathogenesis and onset of depression and other neuropsychiatric disorders. Modulating HPA axis activity, for example via targeted antagonism of the vasopressin V_1b receptor, is a promising approach for patients with depression and other neuropsychiatric disorders associated with HPA axis impairment. Despite favorable preclinical indications in animal models, demonstration of clinical efficacy for the treatment of depressive disorders by targeting HPA axis dysfunction has been challenging, possibly due to the heterogeneity and syndromal nature of depressive disorders. Measures of HPA axis function, such as elevated cortisol levels, may be useful biomarkers for identifying patients who may benefit from treatments that modulate HPA axis activity. Utilizing clinical biomarkers to identify subsets of patients with impaired HPA axis function who may benefit is a promising next step in fine-tuning HPA axis activity via targeted antagonism of the V_1b receptor.

Associations of Thyroid Hormones Profile During Normal Pregnancy and Postpartum With Anxiety, Depression, and Obsessive/Compulsive Disorder Scores in Euthyroid Women

Objective

Thyroid dysfunction (overt and subclinical) has been consistently linked to pregnancy adversity and abnormal fetal growth and development. Mood disorders such as anxiety, depression, and obsessive-compulsive disorder (OCD) are frequently diagnosed during pregnancy and at postpartum, and emerging evidence suggests association with impaired offspring neurodevelopment and growth. This study aimed to examine potential associations between thyroid function and mood symptoms during pregnancy and postpartum.

Design

This is a prospective study measuring thyroid hormones and assessing mood symptoms by employing specific questionnaires in the same cohort of 93 healthy pregnant women at the 24th (2nd trimester) and 36th (3rd trimester) gestational weeks and at the 1st postpartum week.

Methods

Serum thyroid hormones, TSH, anti-TPO, and anti-Tg antibodies were measured at the 24th (2nd trimester) and 36th (3rd trimester) gestational weeks and at the 1st postpartum week. Specific validated questionnaires were employed at the same time-points to assess separately symptoms of anxiety [Generalized Anxiety Disorder Inventory (GADI), Penn State Worry Questionnaire (PSWQ), STAI-State Anxiety inventory (STAI-S), STAI-Trait Anxiety Inventory (STAI-T)], depression [Edinburgh Postnatal Depression Scale (EPDS), Stein’s Blues Scale (BLUES), Beck Depression Inventory (BDI)], and obsessive compulsive disorder (OCD) [Yale-Brown Obsessive Compulsive scale (Y-BOCS)].

Results

At the 2nd trimester, GADI score correlated negatively with FT3 (p < 0.010, r = −0.545) and positively with TSH (p < 0.050, r = 0.837) concentrations; GADI, PSWQ, EPDS and Y-BOCS scores correlated negatively with FT4 concentrations (p < 0.010, r = −0.768; p < 0.010, r = −0.384; p < 0.050, r = −0.364; p < 0.010, r = −0.544, respectively). At the 3rd trimester, BLUES score correlated positively with rT3 concentrations (p = 0.00, r = 0.89); GADI, EPDS, and Y-BOCS scores correlated negatively with FT4 concentrations (p = 0.001, r = − 0.468; p = 0.036, r = −0.39; p = 0.001, r = −0.625, respectively); GADI, STAI-S, and Y-BOCS scores correlated positively with TSH concentrations (p = 0.015, r = 0.435; p = 0.024, r = 0.409 p = 0.041, r = 0.389, respectively). At postpartum, PSWQ, STAI-T, EPDS, and BDI scores correlated positively with rT3 concentrations (p = 0.024, r = 0.478; p = 0.014, r = 0.527; p = 0.046, r = 0.44; p = 0.021, r = 0.556, respectively, Y-BOCS score correlated positively with TSH (p = 0.045, r = 0.43), and BLUES score correlated positively with anti-TPO antibody concentrations (p = 0.070, r = 0.586).

Conclusion

The reported findings demonstrate positive associations between low-normal thyroid function at the 2nd and 3rd trimesters of pregnancy and postpartum with anxiety, depression, and OCD scores.

Neurobiology of peripartum mental illness

At least one in seven pregnant or recently postpartum women will experience a mental illness such as an anxiety disorder, depressive disorder, or substance use disorder. These mental illnesses have detrimental effects on the health of the mother, child, and family, but little is known about the hypothalamic and other neural correlates of maternal mental health concerns. The transition to parenthood alone is a time of remarkable neural plasticity, so it is perhaps not surprising that current research is showing that maternal mental illness has unique neural profiles. Furthermore, the neural systems affected by peripartum mental illness overlap and interact with the systems involved in maternal caregiving behaviors, and mother-infant interactions are, therefore, highly susceptible to disruption. This review discusses what we know about the unique neural changes occurring during peripartum mental illness and the role of the hypothalamus in these illnesses. With an improved understanding of the neural correlates of maternal mental health and disease, we will be better equipped to predict risk, develop effective treatments, and ultimately prevent suffering for millions of parents during this critical time in life.

Neuroendocrine Networks and Functionality

Women undergo developmental and cyclic changes in hormonal exposures that affect brain function and mental health. Some women are more vulnerable to the effects of these hormonal exposures, for reasons that remain to be determined. Evidence to date indicates that anxiety and mood disorders are the most sensitive to hormonal fluctuations in women but there is also growing evidence for a protective effect of female reproductive hormones on schizophrenia. The hormonal exposures of the menstrual cycle, pregnancy, the postpartum period, lactation, and menopause are quite different and may be associated with at least partially distinct symptom profiles.

Pathophysiological mechanisms implicated in postpartum depression

This review aims to summarize the diverse proposed pathophysiological mechanisms contributing to postpartum depression, highlighting both clinical and basic science research findings. The risk factors for developing postpartum depression are discussed, which may provide insight into potential neurobiological underpinnings. The evidence supporting a role for neuroendocrine changes, neuroinflammation, neurotransmitter alterations, circuit dysfunction, and the involvement of genetics and epigenetics in the pathophysiology of postpartum depression are discussed. This review integrates clinical and preclinical findings and highlights the diversity in the patient population, in which numerous pathophysiological changes may contribute to this disorder. Finally, we attempt to integrate these findings to understand how diverse neurobiological changes may contribute to a common pathological phenotype. This review is meant to serve as a comprehensive resource reviewing the proposed pathophysiological mechanisms underlying postpartum depression.

The relationship between labor pain management, cortisol level and risk of postpartum depression development: a prospective nonrandomized observational monocentric trial

Postpartum depression (PPD) is the main psychological status disorder and women suffering from postpartum depression often need long-term psychological and socio-economic rehabilitation. The study is dedicated to the evaluation of the role of labor pain management using epidural analgesia in natural delivery on stress level in labor and frequency of postnatal depression.

Materials and methods

210 women were investigated and divided into two groups. In the first group for labor pain management in natural delivery, patient-controlled epidural analgesia was used (bolus - 10.0 - 0.08% ropivacaine hydrochloride, lockout - 30 min, limit - 120 ml/6 h) with a background of continuous-flow infusion of local anesthetic 0.08% ropivacaine hydrocluoride solution. Patients in the second group had no pain relief in delivery. The stress level was evaluated using blood plasma cortisol level in the early stages of labor, 6 hours and 3 days after delivery. The assessment of depression development was carried out step-by-step: Before the delivery, 6 hours after, 3 days and 6 weeks after the delivery.

Results

The baby blues frequency 6 hours after the delivery in the group where the pain relief was conducted was 29.91%, with cortisol level below and equal to 2310.91 nmol/l. In the group with no pain relief 6 hours after delivery, baby blues was found in 15.53% of puerperas (p < 0.05) and the cortisol level was 2673.82 nmol/l (p < 0.05). Six weeks after the birth, postpartum depression was diagnosed in 4.67% of women who received epidural analgesia during delivery, in comparison to 6.79% with no pain relief during delivery. However, the difference was not statistically significant (p < 0.05).

Conclusions

The use of epidural analgesia leads to a significant reduction of pain syndrome and stress response during natural delivery, increases the risk of baby blues in the early postnatal period, but slightly influences the frequency of postpartum depression.

The association between maternal cortisol and depression during pregnancy, a systematic review

Timing of cortisol collection during pregnancy is an important factor within studies reporting on the association between maternal cortisol and depression during pregnancy. Our objective was to further examine the extent to which reported associations differed across studies according to time of maternal cortisol collection during pregnancy. On December 15, 2016, records were identified using PubMed/MEDLINE (National Library of Medicine), EMBASE (Elsevier; 1974-), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO), PsycINFO (EBSCO), and Web of Science Core Collection (Thomson Reuters). Unique abstracts were screened using the following inclusion criteria: (1) maternal cortisol assessed during pregnancy; (2) antepartum depression assessed during pregnancy using a screening instrument; (3) reports on the association between maternal cortisol and antepartum depression; (4) provides information on timing of cortisol assessment during pregnancy, including time of day and gestation; and (5) not a review article or a case study. One thousand three hundred seventy-five records were identified, resulting in 826 unique abstracts. Twenty-nine articles met all inclusion criteria. On balance, most studies reported no association between maternal cortisol and antepartum depression (N = 17), and saliva and blood were the most common reported matrices. Morning and second and third trimesters were the most common times of collection during pregnancy. Among studies reporting an association (N = 12), second-trimester and third-trimester cortisol assessments more consistently reported an association and elevated cortisol concentrations were observed in expected recovery periods. Our review adds to the existing literature on the topic, highlighting gaps and strategic next steps.

The functioning of the hypothalamic-pituitary-adrenal (HPA) axis in postpartum depressive states: a systematic review

A large body of literature suggests the role of the hypothalamic-pituitary-adrenal (HPA) axis in postpartum depression (PPD). Nonetheless, these studies present discrepant methodology and results; thus, this hypothesis deserves further exploration. Areas covered: This review included studies investigating the HPA axis in PPD or postpartum blues published until November 2016. In total, 48 studies met the inclusion criteria. The HPA axis was mostly investigated in the immediate postpartum period (62.5%), and the majority of studies collected samples in the morning (43.8%), with one measure in a single day (43.8%), and blood was the fluid more often collected (58.4%). Seven out of 21 studies evaluating postpartum blues, and 15 out of 28 studies evaluating PPD detected abnormalities in the HPA axis functioning. Expert commentary: We found a significant heterogeneity in the methodology adopted by studies and consequently, in the results. Despite that, the majority of studies reported HPA changes in women with PPD during the remote period. Notably, reactivity tests pointed to attenuated HPA axis response. Ideally, future investigations should use validated reactivity tests, include larger sample sizes, consider many measures of cortisol throughout the day, and more than one day of collection. We also recommend that studies continue to use validated scales for mood assessment.

Neuroendocrine Networks and Functionality

Women undergo developmental and cyclic changes in hormonal exposures that affect brain function and mental health. Some women are more vulnerable to the effects of these hormonal exposures, for reasons that remain to be determined. Evidence to date indicates that anxiety and mood disorders are the most sensitive to hormonal fluctuations in women but there is also growing evidence for a protective effect of female reproductive hormones on schizophrenia. The hormonal exposures of the menstrual cycle, pregnancy, the postpartum period, lactation, and menopause are quite different and may be associated with at least partially distinct symptom profiles.

Perinatal maternal depression and cortisol function in pregnancy and the postpartum period: a systematic literature review

BACKGROUND

Perinatal depression has a significant impact on both mother and child. However, the influence of hormonal changes during pregnancy and the postpartum period remains unclear. This article provides a systematic review of studies examining the effects of maternal cortisol function on perinatal depression.

METHOD

A systematic search was conducted of six electronic databases for published research on the relationship between cortisol and perinatal depression. The databases included; MEDLINE complete, PsychINFO, SCOPUS, Psychology and Behavioural Sciences, Science Direct and EBSCO, for the years 1960 to May 2015. Risk of bias was assessed and data extraction verified by two investigators.

RESULTS

In total, 47 studies met criteria and studies showed considerable variation in terms of methodology including sample size, cortisol assays, cortisol substrates, sampling processes and outcome measures. Those studies identified as higher quality found that the cortisol awakening response is positively associated with momentary mood states but is blunted in cases of major maternal depression. Furthermore, results indicate that hypercortisolemia is linked to transient depressive states while hypocortisolemia is related to chronic postpartum depression.

DISCUSSION AND CONCLUSION

Future research should aim to improve the accuracy of cortisol measurement over time, obtain multiple cortisol samples in a day and utilise diagnostic measures of depression. Future studies should also consider both antenatal and postnatal depression and the differential impact of atypical versus melancholic depression on cortisol levels, as this can help to further clarify the relationship between perinatal depression and maternal cortisol function across pregnancy and the postpartum period.

Altered stress patterns and increased risk for postpartum depression among low-income pregnant women

Postpartum depression (PPD) has been associated with a number of negative maternal and infant health outcomes. Despite these adverse health effects, few studies have prospectively examined patterns of pre- and postnatal stress that may increase a woman's risk for PPD. The current study examined whether the timing of altered salivary cortisol patterns and perceived stress levels during pregnancy and at 3 months postpartum was associated with PPD symptoms among 100 low-income mothers. Higher levels of PPD were found among women with a lower cortisol awakening response (first and second trimester), lower average daily cortisol (second trimester), a flatter diurnal cortisol pattern (second and third trimester and at 3 months postpartum), and a less abrupt drop in both cortisol and perceived stress from the third trimester to 3 months postpartum. These results support the need for early screening and regulation of stress levels to promote depression prevention efforts in at-risk populations.

Perinatal Major Depression Biomarkers: A systematic review

Postpartum depression, now termed perinatal depression by the DSM-5, is a clinically relevant disorder reaching 15% of incidence. Although it is quite frequent and associated with high social dysfunction, only recently its underpinning biological pathways have been explored, while multiple and concomitant risk factors have been identified (e.g. psychosocial stress). Peripartum depression usually has its onset during the third trimester of pregnancy or in the postpartum, being one of the most common medical complications in new mothers. Purpose of the present review is to summarize the state of art of biological biomarkers involved in the pathogenesis of perinatal depression, in view of the fact that suboptimal prenatal milieu can induce permanent damage in subsequent offspring life and have a negative impact on mother-child relationship. Furthermore, parents' biological changes due to medical/psychiatric disorders or stress exposure could influence offspring life: a concept known as 'intergenerational transmission', acting by variations into gametes and the gestational uterine environment. Given the evidence that perinatal mental disorders involve risks for the mother and offspring, the search for reliable biomarkers in high-risk mothers actually represents a medical priority to prevent perinatal depression.

Altered functioning of the HPA axis in depressed postpartum women

BACKGROUND

The present study aimed to evaluate the relationship between the functioning of the hypothalamic-pituitary-adrenal (HPA) axis and major depressive episodes in the remote postpartum period.

METHODS

The sample (mean age, 28.0±5.3 years) consisted of 37 depressed postpartum women (DPP), 42 euthymic postpartum women (EPP) and 25 non-postpartum healthy women (HC). Salivary cortisol samples were collected immediately after awakening and 30min, 3 and 12h later, at approximately the sixth month postpartum (mean, 169.6±60.3 days).

RESULTS

Differences in cortisol levels were observed at awakening (DPP<EPP=HC), at 30min (DPP<EPP<HC), at 3h (DPP=EPP<HC) and at 12h (DPP>EPP=HC). The relative increment in the cortisol awakening response (CARi%) was significantly higher in HC (113.5±94.3) than in EPP (63.1±69.8) and DPP (32.2±49.6). The relative reduction in diurnal variation (DVr%) was lower in DPP (56.5±41.8) than in EPP (75.6±22.4) and HC (75.1±13.0).

LIMITATIONS

The main limitation was cortisol collection on a single day and without measurement at midnight.

CONCLUSIONS

Our findings suggest that the remote postpartum period involves attenuation of HPA axis reactivity; this dysregulation is more pronounced in the presence of DPP, which is associated with a reduction in cortisol diurnal variation. Abnormalities in the neuroendocrine system related to stress processing, present even several months after delivery, can represent vulnerability to mental disorders. Thus, improvements in the mental health care of postpartum women are needed.

Late pregnancy thyroid-binding globulin predicts perinatal depression

Previously we found that late pregnancy total and free thyroxine (TT4, FT4) concentrations were negatively related to greater pre and/or postpartum depressive symptoms. In a much larger cohort, the current study examined whether these thyroid indices measured earlier in the third trimester (31-33 weeks) predict subsequent perinatal depression and anxiety ratings as well as syndromal depression. Thyroid-binding globulin (TBG) concentrations increase markedly during pregnancy and may be an index of sensitivity to elevated estrogen levels. TBG was examined in this study because prior findings suggest that postpartum depression is related to sensitivity to mood destabilization by elevated sex hormone concentrations during pregnancy. Our cohort was 199 euthyroid women recruited from a public health obstetrics clinic (63.8% Hispanic, 21.6% Black). After screening and blood draws for hormone measures at pregnancy weeks 31-33, subjects were evaluated during home visits at pregnancy weeks 35-36 as well as postpartum weeks 6 and 12. Evaluations included psychiatric interviews for current and life-time DSM-IV psychiatric history (M.I.N.I.-Plus), subject self-ratings and interviewer ratings for depression and anxiety (Edinburgh Postnatal Depression Scale, Montgomery-Ǻsberg Depression Rating Scale; Spielberger State-Trait Anxiety Inventory, Hamilton Anxiety Inventory), as well as a standardized interview to obtain life-time trauma history. Numerous covariates were included in all regression analyses. Trauma and major depression history were robustly significant predictors of depression and anxiety ratings over the study period when these variables were analyzed individually or in a combined model including FT4 or TBG (p<.001). When analyzed alone, FT4 levels were a less strong but still significant predictor of all depression and anxiety ratings (p<.05) while TBG levels was a significant or nearly significant predictor of most ratings. FT4, TBG and trauma history, but not major depression history, were significant individual predictors of syndromal depression during the study period (p<.05) in single predictor models. In models combining each with trauma and major depression history, FT4 and TBG generally were not significantly predictive of depression or anxiety ratings, and FT4 was also not a significant predictor of syndromal depression: however, in the combined model TBG was a particularly strong predictor of perinatal syndromal depression (p=.005) and trauma history was also significant (p=.016). Further study of the interactions among TBG, FT4, sex hormones, trauma history and perinatal depression may provide insights into the pathophysiological basis of individual variance in vulnerability to mood destabilization by the hormone conditions of pregnancy.

Prenatal and Postpartum Evening Salivary Cortisol Levels in Association with Peripartum Depressive Symptoms

BACKGROUND

The biology of peripartum depression remains unclear, with altered stress and the Hypothalamus-Pituitary-Adrenal axis response having been implicated in its pathophysiology.

METHODS

The current study was undertaken as a part of the BASIC project (Biology, Affect, Stress, Imaging, Cognition), a population-based longitudinal study of psychological wellbeing during pregnancy and the postpartum period in Uppsala County, Sweden, in order to assess the association between evening salivary cortisol levels and depressive symptoms in the peripartum period. Three hundred and sixty-five pregnant women from the BASIC cohort were recruited at pregnancy week 18 and instructed to complete a Swedish validated version of the Edinburgh Postnatal Depression Scale at the 36th week of pregnancy as well as the sixth week after delivery. At both times, they were also asked to provide evening salivary samples for cortisol analysis. A comprehensive review of the relevant literature is also provided.

RESULTS

Women with postpartum EPDS score ≥ 10 had higher salivary evening cortisol at six weeks postpartum compared to healthy controls (median cortisol 1.19 vs 0.89 nmol/L). A logistic regression model showed a positive association between cortisol levels and depressive symptoms postpartum (OR = 4.1; 95% CI 1.7-9.7). This association remained significant even after controlling for history of depression, use of tobacco, partner support, breastfeeding, stressful life events, and sleep problems, as possible confounders (aOR = 4.5; 95% CI 1.5-14.1). Additionally, women with postpartum depressive symptoms had higher postpartum cortisol levels compared to both women with depressive symptoms antenatally and controls (p = 0.019 and p = 0.004, respectively).

CONCLUSIONS

Women with depressive symptoms postpartum had higher postpartum cortisol levels, indicating an altered response of the HPA-axis in postpartum depression.

The role of reproductive hormones in postpartum depression

Despite decades of research aimed at identifying the causes of postpartum depression (PPD), PPD remains common, and the causes are poorly understood. Many have attributed the onset of PPD to the rapid perinatal change in reproductive hormones. Although a number of human and nonhuman animal studies support the role of reproductive hormones in PPD, several studies have failed to detect an association between hormone concentrations and PPD. The purpose of this review is to examine the hypothesis that fluctuations in reproductive hormone levels during pregnancy and the postpartum period trigger PPD in susceptible women. We discuss and integrate the literature on animal models of PPD and human studies of reproductive hormones and PPD. We also discuss alternative biological models of PPD to demonstrate the potential for multiple PPD phenotypes and to describe the complex interplay of changing reproductive hormones and alterations in thyroid function, immune function, hypothalamic-pituitary-adrenal (HPA) axis function, lactogenic hormones, and genetic expression that may contribute to affective dysfunction. There are 3 primary lines of inquiry that have addressed the role of reproductive hormones in PPD: nonhuman animal studies, correlational studies of postpartum hormone levels and mood symptoms, and hormone manipulation studies. Reproductive hormones influence virtually every biological system implicated in PPD, and a subgroup of women seem to be particularly sensitive to the effects of perinatal changes in hormone levels. We propose that these women constitute a "hormone-sensitive" PPD phenotype, which should be studied independent of other PPD phenotypes to identify underlying pathophysiology and develop novel treatment targets.

Thyroid function tests at delivery and risk for postpartum depressive symptoms

Postpartum depression (PPD) is a common childbirth complication, which can have negative effects on both the newly delivered woman and her family. This condition is underdiagnosed and inadequately treated, while a biological diagnostic test is not yet available. Furthermore, postpartum thyroid dysfunction is common among new mothers, and some evidence point to an association between PPD and thyroid function disturbances. The aim of this study was to evaluate the possible association between serum levels of thyroid hormones at the time of delivery, and the later development of depressive symptoms, using data from a population based cohort of Swedish women. Blood samples were collected during delivery from 347 participating women, delivering at Uppsala University Hospital. The participating women filled in at least one of three structured questionnaires, containing the Edinburgh Postnatal Depression Scale (EPDS), at five days, six weeks and six months postpartum. A cut-off of 12 or more was applied on the EPDS, to identify cases of self-reported PPD and controls. Using a binary logistic regression model (adjusting for previous psychiatric contact, smoking during pregnancy, pre-pregnancy body mass index (BMI) and sleep), having a thyroid stimulating hormone (TSH) level over the clinical cut-off level of 4.0 mU/L was associated with increased risk for depressive symptoms at six months postpartum (OR 11.30, 95% CI 1.93-66.11). A ROC analysis revealed that the predictive variable (PV) had significant predictive ability for PPD at 6 months postpartum, given that the AUC was 0.764, and at a PV cut-off value of 6.33, the sensitivity and specificity were 76.2% and 69.4%, respectively. If these findings are replicated in future studies, they can have important clinical implications, since TSH determination is an inexpensive routine blood test, and its inclusion in a biological screening test for PPD involving other parameters would be tempting.

Biological aspects of postpartum depression

In comparison with the vast epidemiological literature on postpartum depression (PPD), relatively few studies have examined the biological aspects of the disorder. However, research into the biological mechanisms of PPD is a challenging task, as normal pregnancy and the postpartum period cause adaptive endocrine changes, which would otherwise be considered pathological in nonpregnant women. This review focuses on the adaptive changes of childbearing and nursing, which ultimately may put women at increased risk of PPD. In light of the normal physiology, the authors also attempt to describe the current evidence of the biological changes associated with the development of depression in the postpartum period, including ovarian steroids, the hypothalamic-pituitary-adrenal axis, the serotonergic neurotransmitter system, the thyroid system and inflammatory markers. In addition, current knowledge on candidate genes associated with PPD is reviewed.

Predictors of postpartum depression in a sample of Egyptian women

INTRODUCTION

Postpartum depression (PPD) represents a considerable health problem affecting women and their families. The aims of this study were to: (a) compare female patients with PPD to normal controls with regard to some biopsychosocial variables, (b) correlate between the severity of PPD and some clinical and biological variables, and (c) to predict some risk factors for PPD.

METHOD

Sixty female patients with PPD were compared with 60 healthy postpartum females (control group). Patient and controls were subjected to: (1) a complete psychiatric and obstetric examination, (2) psychometric studies using the Edinburgh Postnatal Depression Scale, Fahmy and El-Sherbini's Social Classification Scale for Egyptian socioeconomic classification and Horowitz et al's Impact of Event Scale, (3) quantities of thyroid hormone (T3), cortisol hormone, and estrogen were assessed.

RESULTS

There were high statistical differences between PPD females and controls as regard psychosocial stressors, level of (estradiol, thyroxin [T3], and cortisol), marital status, residence, parity, method of delivery, complicated puerperium, positive history of premenstrual tension syndrome and baby variables (eg, unwelcomed, with a negative attitude of parents toward the baby, underweight, female, artificially feeding, unhealthy baby). While there were moderate statistical differences in attitude toward spouse and social support and mild statistical difference in socioeconomic status between them. Severity of depression is positively highly correlated with onset of depression, psychosocial stress, levels of T3 and cortisol. However, severity of depression is negatively high when correlated with socioeconomic status. Stepwise linear regression indicated that PPD was significantly predicted by social support, socioeconomic status, feeding of baby, and prior psychiatric problems.

CONCLUSION

Many factors may lead to development of PPD. These factors include some psychosocial, socioeconomic, obstetric, and hormonal variables. Early detection of these factors could help in prediction of the development of PPD.

Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women

Mood disorders disproportionately affect women across the lifespan. Mood disorders in pregnancy and the postpartum period are common and have profound implications for women and their children. These include obstetric and neonatal complications, impaired mother-infant interactions, and, at the extreme, maternal suicide and infanticide. Because obstetrician-gynecologists are often the first (and sometimes the only) point of contact for young women in the health care system, familiarity with the presentation and treatment of depressive illness in the perinatal period is imperative. The goal of this review is to synthesize essential information on depressive illness in the perinatal period with a focus on its most common and severe presentations, major depressive disorder and bipolar disorder. Accurate diagnosis of unipolar major depressive disorder from bipolar disorder can facilitate the selection of the best possible treatment alternatives. Counseling may be sufficient for perinatal women who have mild to moderate depression, but women who are severely depressed are likely to require antidepressant treatment. Women with bipolar disorder are at high risk for relapse if mood stabilizer medication is discontinued, and they are vulnerable to relapse near the time of delivery. Comanagement of their care with psychiatrists will increase their chances of avoiding a recurrence of illness.

Failed lactation and perinatal depression: common problems with shared neuroendocrine mechanisms?

In the early postpartum period, mother and infant navigate a critical neuroendocrine transition from pregnancy to lactation. Two major clinical problems that occur during this transition are failed lactation and perinatal mood disorders. These disorders often overlap in clinical settings. Failed lactation is common. Although all major medical organizations recommend 6 months of exclusive breastfeeding, only 13% of women in the United States achieve this recommendation. Perinatal mood disorders affect 10% of mothers, with substantial morbidity for mother and child. We hypothesize that shared neuroendocrine mechanisms contribute to both failed lactation and perinatal mood disorders. In this hypothesis article, we discuss data from both animal models and clinical studies that suggest neuroendocrine mechanisms that may underlie these two disorders. Research to elucidate the role of these underlying mechanisms may identify treatment strategies both to relieve perinatal depression and to enable women to achieve their infant feeding goals.

Childhood sexual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression

OBJECTIVE

The aim of this study was to investigate the association between early life events in women with postpartum major depression and concomitant hypothalamus-pituitary-thyroid axis disturbances (HPTD), thyroid dysfunction or presence of thyroid antibodies.

METHODS

Serum total tri-iodothyronine (TT3), free thyroxin (FT4), Thyroid-stimulating hormone (TSH), Thyroperoxidasa (TPOAb) and Thyroglobulin (TGAb) autoantibodies was measured in 103 major postpartum depressive women. HPTD was defined as TSH and/or T4 abnormal, presence of thyroid autoantibodies and alterations of TT3. All women were assessed with a psychiatry structured interview for DSM-IV. Early Trauma Inventory Self Report, sociodemographic, reproductive, psychosocial and psychopathological variables were also assessed.

RESULTS

Sixty three percent of women had suffered childhood trauma, which was childhood sexual abuse in 27.2%. Childhood sexual abuse in postpartum major depression women increased the risk for thyroid dysfunction (OR=5.018, 95%CI=1.128-22.327), presence of thyroid autoantibodies (OR=2.528; 95%CI=1.00-6.39) and HPTD (OR=2.955; 95%CI=1.191-7.32). Moreover, age over 34 (OR=12.394; 95%CI=1.424-107.910) and previous postpartum depression (OR=8.470; 95%CI=1.20-59.43) increased the risk for thyroid dysfunction in postpartum depression.

LIMITATIONS

The study design does not allow us to know the direction of the association and there is a lack of previous assessment of current posttraumatic stress disorder.

CONCLUSIONS

According to the present findings, childhood sexual abuse may represent an important risk factor for the presence of thyroid autoantibodies and HPTD in women with postpartum depression.

Thyroid function and postpartum mood disturbances in Greek women

BACKGROUND

Postpartum mood disturbances are very common with postpartum blues being as high as 44.5% among Greek women. This study aimed to investigate whether thyroid function within the normal range affects the incidence of postpartum mood disturbances.

METHODS

In a cross-sectional study in the maternity ward of Aretaieion Hospital, 57 Greek women were evaluated for postpartum mood swings by the Maternity Blues Questionnaire and the Edinburgh Postnatal Depression Scale on the first and sixth week postpartum. Serum Free T4, Free T3 and TSH concentrations as well as thyroglobulin and thyroid peroxidase antibodies were measured on admission for delivery and daily until the fourth postpartum day. We examined the association between hormone and antibody levels, and scores in the two scales evaluating postpartum mood disturbances.

RESULTS

Prepartum serum FT3 and FT4 correlated negatively with blues scores in the first week postpartum (blues on day 4: with FT3, rho=-0.44, p < or = 0.01; with FT4 rho=-0.36, p < or = 0.01). Women with lower FT3 and FT4 levels belonged to the high scoring group (high scoring group: FT3=1.22 pg/ml, FT4=0.66 ng/dl; low scoring group: FT3=1.64 pg/ml, FT4=0.73 ng/dl). Serum FT3 showed a negative independent correlation with postpartum blues scores in the first postpartum days. No association was found between thyroid antibody levels and mood scores.

CONCLUSION

Our findings indicate an association between the occurrence of postpartum mood disorders and antenatal thyroid function. Within normal limits, lower levels of serum FT3 and FT4 are associated with increased incidence of mood disturbances in the first postpartum week.

The psychoneuroimmunology of postpartum depression

Postpartum depression (PPD) is a potentially debilitating disorder that develops in a significant percentage of women during the first year after giving birth. Women afflicted with PPD experience long-term consequences, including sadness, guilt, and despair. Offspring may be affected as well. Several investigators have tested psychosocial risk factors for the development of PPD; however, substantial amounts of variance in PPD have gone unexplained with regression on psychosocial variables alone. Likewise, interventions for PPD that have focused on psychosocial risk factors alone have been largely unsuccessful. The unexplained variance and disappointing treatment success could well be due to investigators' failure to address relevant biological changes occurring during the postpartum period. Two biological systems that are affected significantly and remain in flux during the postpartum period are the innate immune system and the hypothalamic-pituitary-adrenal (HPA) axis. Bidirectional interactions between these two systems are well established, and it is generally acknowledged that dysfunction in either system can lead to depression in nonpregnant, nonpostpartum populations. To date, little research has pursued the contribution of these interacting systems to the development of PPD. The purpose of this paper is to review the psychoneuroimmunology of PPD. The central hypothesis presented is that dysregulation in either system individually or in their bidirectional interaction is associated with the development of PPD.

Parity mediates the association between infant feeding method and maternal depressive symptoms in the postpartum

Maternal depression is the most common complication of the postpartum, having devastating and long lasting effects on mother and infant. Lactation is associated with attenuated stress responses, especially that of cortisol, and the lactogenic hormones, oxytocin and prolactin, are associated with anti-depressant and anxiolytic effects. These associations suggest that breast-feeding may decrease maternal depressive symptoms, yet empirical results have been conflicting. Recent findings have indicated that parity may mediate the association between breast-feeding and stress response. Because a decreased stress response is associated with a decreased risk for depression, parity may also mediate the association between infant feeding method and depressive symptoms. Specifically, the benefits of breast-feeding may appear in multiparous but not primiparous mothers. In the present study, data drawn from a national sample of primiparous and multiparous mothers were examined for possible associations between infant feeding method and depressive symptoms, as assessed by the Center for Epidemiological Survey-Depression scale (CES-D). After controlling for several possible confounding variables, breast-feeding by multiparas was associated with significantly decreased odds of having depression compared with bottle-feeders (OR = 0.41, CI 0.19-0.87, p = 0.02); however, no risk reduction from breast-feeding was evident among primiparas. The results support a parity-mediated association between lactation and maternal depressive symptoms. The results provide a reason for earlier conflicting findings, present new research avenues, and suggest possible clinical approaches.

Perinatal depression: hiding in plain sight

OBJECTIVE

To promote prompt identification and treatment ofperinatal depression and enhance preventive care for women at risk.

METHODS

Using MEDLINE and PubMed searches, we reviewed the recent research on the origins, course, and consequences of pregnancy-related depression.

RESULTS

Depressive disorders are more common in pregnancy and postpartum than widely assumed, and there is no predictable protective effect of pregnancy. Relapse rates are high, and the postpartum period represents a time of increased vulnerability to depression.

CONCLUSION

Early identification and treatment ofperinatal depression will minimize morbidity and mortality for the woman, the child, and the family.

Persistent alterations in biological profiles in women with abuse histories: influence of premenstrual dysphoric disorder

OBJECTIVE

To examine dysregulation in biological measures associated with histories of abuse in women and whether women with premenstrual dysphoric disorder (PMDD) differ in their dysregulation.

DESIGN

Twenty-five women meeting prospective criteria for PMDD and 42 non-PMDD controls underwent structured interview to determine abuse histories and lifetime Axis I diagnoses, excluding those with current Axis I disorders or using medications.

MAJOR OUTCOME MEASURES

Plasma cortisol and norepinephrine (NE), heart rate (HR), blood pressure (BP), and vascular resistance index (VRI) were assessed at rest and in response to mental stress.

RESULTS

A greater proportion of PMDD women had prior abuse compared with non-PMDD women. Regardless of PMDD status, all abused women had lower plasma NE and higher HRs and tended to have lower plasma cortisol at rest and during stress. Abused women also reported more severe daily emotional and physical symptoms. Greater VRI and BP at rest and during stress were seen only in PMDD women with abuse.

CONCLUSION

There is persistent dysregulation in stress-responsive systems in all abused women that cannot be accounted for by current psychiatric illness or medications, and PMDD women may be differentially more vulnerable to the impact of abuse on measures reflecting alpha-adrenergic receptor function.

Neurosteroids in the context of stress: implications for depressive disorders

Animal models indicate that the neuroactive steroids 3alpha,5alpha-THP (allopregnanolone) and 3alpha,5alpha-THDOC (allotetrahydroDOC) are stress responsive, serving as homeostatic mechanisms in restoring normal GABAergic and hypothalamic-pituitary-adrenal (HPA) function following stress. While neurosteroid increases to stress are adaptive in the short term, animal models of chronic stress and depression find lower brain and plasma neurosteroid concentrations and alterations in neurosteroid responses to acute stressors. It has been suggested that disruption in this homeostatic mechanism may play a pathogenic role in some psychiatric disorders related to stress. In humans, neurosteroid depletion is consistently documented in patients with current depression and may reflect their greater chronic stress. Women with the depressive disorder, premenstrual dysphoric disorder (PMDD), have greater daily stress and a greater rate of traumatic stress. While results on baseline concentrations of neuroactive steroids in PMDD are mixed, PMDD women have diminished functional sensitivity of GABA(A) receptors and our laboratory has found blunted allopregnanolone responses to mental stress relative to non-PMDD controls. Similarly, euthymic women with histories of clinical depression, which may represent a large proportion of PMDD women, show more severe dysphoric mood symptoms and blunted allopregnanolone responses to stress versus never-depressed women. It is suggested that failure to mount an appropriate allopregnanolone response to stress may reflect the price of repeated biological adaptations to the increased life stress that is well documented in depressive disorders and altered allopregnanolone stress responsivity may also contribute to the dysregulation seen in HPA axis function in depression.

Antenatal thyroid correlates of postpartum depression

We previously found significantly higher T3-resin uptake and nearly significantly lower total thyroxine concentrations at 38 weeks of pregnancy in women with higher postpartum depression ratings. This study further examined the relationship between thyroid status during late pregnancy and antenatal and postpartum depression scores. Thyroid measures were obtained at 32-35, 36, and 37 weeks of pregnancy in 31 women with normal range thyroid hormone levels. Subjects rated their mood at these antenatal time points and every other week between postpartum weeks 2 and 24 on the Edinburgh Postnatal Depression Scale and the Beck Depression Inventory. Mean antenatal thyroxine concentrations and free thyroxine indices correlated significantly and negatively with mean depression scores during each of three postpartum time periods (postpartum weeks 2-6, 14-18, 20-24). Women with total and free thyroxine concentrations that were, respectively, <10.1 microg/dl and <1.06 ng/dl at all three antenatal time points had significantly higher mean depression scores during all postpartum time periods. The fraction of subjects with pregravid major or minor depression history that was in the low antenatal thyroid group was significantly higher than the fraction of subjects with negative history (5/6 vs. 7/25). Women with antenatal total and free thyroxine concentrations in the lower euthyroid range may be at greater risk of developing postpartum depressive symptoms. Study of the relationships with antenatal thyroid status may provide new insights into the pathophysiology of perinatal mood disturbances.

Are stress-induced cortisol changes during pregnancy associated with postpartum depressive symptoms?

OBJECTIVE

The purpose of this study was to examine the association between psychobiological stress reactivity during healthy pregnancy and depressive symptoms in the early puerperium.

METHODS

A sample of healthy nulliparous pregnant women (N = 57) between the ages of 21 and 35 years underwent a standardized psychosocial stress test during pregnancy. Within an average of 13 days after delivery, postpartum depressive symptoms were assessed using the German version of the Edinburgh postnatal depression scale (EPDS). The sample was divided into a group with probable cases (EPDS score >9, N = 16) and a group with probable noncases (EPDS score < or =9, N = 41).

RESULTS

The probable case group showed significantly higher cortisol responses to the stress test compared with the probable noncase group, whereas baseline levels did not differ. Additionally, women in the probable case group showed significantly higher state anxiety and lower mood state throughout the experiment. Furthermore, the probable case group showed higher stress susceptibility, higher trait anxiety, and higher levels in the Symptom Checklist. No differences were found for prior episodes of psychiatric disorders, obstetrical complications, birth weight, or mode of delivery.

CONCLUSIONS

Our data provide evidence that healthy pregnant women developing postpartum depressive symptoms might already be identified during pregnancy by means of their higher cortisol reactivity and their higher psychological reactivity in response to psychosocial stress. Further investigations are required to explore whether higher psychobiological stress responses not only precede depressive symptoms within 2 weeks after birth, but might also predict postpartum major depression.

Psychiatric disorders in pregnancy

This review, although not exhaustive, provides information on the potential impact of psychiatric illness on obstetric outcome. There is clear evidence that psychiatric illness poses a risk to pregnancy outcome. There productive safety data on many of the available treatments fail to demonstrate a clear risk from treatment. The medications with clear teratogenic, neonatal, and developmental risks are, not surprisingly, those used to treat some of the most severe and debilitating psychiatric illnesses. Even the amount of information available is inadequate without some straightforward clinical guidelines. A model of risk for illness and treatments of illnesses during pregnancy developed by the authors' group reminds clinicians that nonexposure does not exist. Rather, the decision is which type of exposure is in the best interest of the patient and family-exposure to illness or exposure to treatment. Regardless of the choice, clinicians are encouraged to think in terms of reducing the total number of exposures; that is, if choosing to treat, patients should be kept well by adjusting and monitoring medications-partial treatment simply provides exposure to illness and treatment. Guidelines to accomplish the goal of minimizing exposures include: 1. Treating women of reproductive capacity from the first visit as if they are pregnant: choosing treatments with reproductive safety information (eg, new and improved = no data) and providing supplemental folic acid for all women (800 microg), with higher doses for those treated with anticonvulsants (3 to 4 mg).2. For women who conceive while taking a medication, and if it was efficacious for them, then the majority of decisions for medication selection should be considered already made for pregnancy and lactation (eg, do not switch medications once pregnant or for breastfeeding, as that simply exposes the baby to a second medication and the data previously discussed do not apply). 3. Because the serum concentration of most medications decreases during pregnancy, establishing criteria a priori for increasing the maternal daily dose; as a general rule, sleep patterns are good markers of psychiatric illnesses. 4. Always preferring monotherapy to two medications. 5. Obtaining up-to-date information at www.emorywomensprogram.org (a website with links to many support groups, reproductive safety registries) or other women's health websites. These basic guidelines can help decrease the number of exposures and aid in conducting clinical care with at least some reproductive safety data.

Alterations in platelet serotonin transporter binding in women with postpartum onset major depression

There is considerable debate as to whether postpartum depression (PPD) is biologically distinct from other depressive syndromes. Although abnormalities in serotonergic neural systems have repeatedly been reported in depression, few such studies have been conducted in PPD. In the present study, platelet serotonin transporter (SERT) binding was assessed using [(3)H]paroxetine in 14 depressed pregnant women, 31 normal healthy pregnant women, 39 depressed postpartum women, and 27 normal healthy postpartum women; all of the subjects were drug-free. Significant differences were detected among the 4 groups with respect to the dissociation constant (Kd) of platelet binding sites for [(3)H]paroxetine with the highest Kd values among those with PPD. The density (Bmax) of platelet binding sites for [(3)H]paroxetine did not differ between the study groups. These data suggest that PPD may be associated with unique alterations in serotonergic function that are specific to the puerperium.

Postpartum mood disorders: a review of clinical and epidemiological factors

The postpartum period is a time of risk for mood disturbance in women. Postpartum blues occurs commonly, but is self-limited. Postpartum depression occurs in 13% of postpartum women. However, it is estimated that nearly one-half of all cases go undetected. Postpartum psychosis is rare, affecting 1-2 per 1000 women. Postpartum mood disorders can have far-reaching consequences and have been shown to affect the social and psychological development of children. It is critical that healthcare providers understand these disorders and their risk factors to increase detection and to educate women about the risks and treatments of postpartum mood disorders. This review is intended to provide healthcare providers with a better understanding of the descriptive epidemiology, risk factors, and treatments of postpartum mood disorders. The utility of specific screening instruments is also discussed.

Abnormal, abusive, and stress-related behaviors in baboon mothers

BACKGROUND

Psychiatric disturbances during pregnancy and the postpartum period are especially serious, given the negative effects on the mother as well as the child. Understanding the causes of such disturbances has been difficult owing to the complexity of psychological, social, experiential, biological, and genetic factors involved.

METHODS

To determine the potential utility of a nonhuman primate model for the study of postpartum disorders, the pathologic and stress-related behavior of 62 female baboons living in social groups was studied during pregnancy and after the birth of an infant.

RESULTS

The prevalence of abnormal behavior and self-directed scratching (a measure of stress response) was higher after birth of the infant. Subjects displayed a significantly higher frequency per hour of these behaviors postpartum, which increased over 8 weeks. Abusive behaviors toward the infant were common, occurring in 55% of the subjects. Mothers with low dominance rank, who usually have lower levels of social support, had higher levels of abusive behavior during the postpartum period.

CONCLUSIONS

Baboons show variation in measurable behaviors related to stress and abnormal functioning during the pre- and postpartum periods, indicating that a nonhuman primate model may be useful in the study of factors affecting postpartum psychiatric disorders and infant abuse.

Antidepressants during pregnancy and lactation: defining exposure and treatment issues

The majority of psychiatric illness onsets early in an individual's life, typically before or during the reproductive years. The increased incidence of major depression, dysthymia, and panic disorder in women compared with men underscores the likelihood that the clinician will encounter the clinical dilemma of medication use during pregnancy and lactation. The emergence of specialized clinics at several academic centers specifically to investigate and address issues in Perinatal psychiatry illustrates this conundrum best. The extant literature derived from human studies suggests that maternal mental illness and stress may have an adverse impact on obstetrical outcome. These clinical investigations are complemented by a burgeoning series of laboratory studies in rodents and nonhuman primates, showing the profound deleterious impact of maternal stress during the perinatal and neonatal periods on the development of the offspring. Data obtained from pharmaceutical registries, cohort studies, toxicology centers, and case series have consistently failed to show an adverse effect associated with in utero antidepressant exposure. Despite these advances and treatment guidelines proposed by the various academic leaders, investigations describing the extent of fetal/neonatal exposure, clinical methods for minimizing such exposure, and clinical treatment guidelines that include the physiological impact of pregnancy are sparse. The available literature shows distinct pharmacokinetic profiles of the selective serotonin reuptake inhibitors in placental passage and breast milk. Preliminary animal studies have shown higher than expected central nervous system concentrations associated with exposure during pregnancy and mathematical modelling for calculating infant exposure when nursing. The clinical import of these data will require further investigations of central nervous system bioavailability in the fetus and neonate.

Postpartum mood and anxiety disorders: a guide for the nonpsychiatric clinician with an aside on thyroid associations with postpartum mood

This article summarizes the considerable progress that has been made in recent years in our understanding of the risks of pregnancy-associated mood and anxiety disorders, effective somatic and nonsomatic treatments for those disorders, and the risks and benefits of psychotropic medications during pregnancy and breast-feeding. Ten to 15% of women develop syndromal depressions within the first 2 to 3 months postpartum, making this the most common serious medical complication of the puerperium. Prior history of depressive disorders, lack of social support, and stressful life events all increase the risk of postpartum depression. Psychotic mood disorders (commonly called postpartum psychosis) occur after approximately 1 to 2 deliveries per 1000. To ensure safety, women who develop postpartum psychotic symptoms should be hospitalized. History of bipolar illness increases the risk of postpartum psychosis to as much as 25%. Prior episodes of postpartum psychosis further increase the risk to 50%-75%. The risk of first onset or exacerbation of panic disorder or obsessive-compulsive disorder appears to increase during pregnancy and the puerperium. Postpartum mood and anxiety disorders are highly responsive to psychotherapy and in more serious cases, to medication. Fortunately, several classes of psychotropic medications, especially tricyclic and selective serotonin reuptake inhibitor antidepressants, appear to be reasonable safe during pregnancy and breast-feeding. Electroconvulsive therapy is the most effective treatment for very severe postpartum mood disorders, including postpartum psychosis. Preliminary results are also presented that suggest that lower range total and free thyroxine concentrations during late pregnancy are related to postpartum depressive symptoms.

Psychoendocrinology. A commentary

This article provides an outline of both the descriptive and the therapeutic sides of human psychoendocrinology. Attention is given to both the history and future prospects of the discipline. Examples are chosen from both basic and clinical science to illustrate the accomplishments and promise of the field as well as its relationship to its cognate discipline psychopharmacology and the dependence of both on progress in psychiatric nosology.

Psychoneuroendocrinology of mood disorders. The hypothalamic-pituitary-thyroid axis

Abnormal thyroid functioning can affect mood and influence the course of unipolar and bipolar disorder. Even mild thyroid dysfunction has been associated with changes in mood and cognitive functioning. Thyroid hormone supplementation may have role in the treatment of certain mood disorders, particularly rapid-cycling bipolar disorder. Women are more vulnerable to thyroid dysfunction than men and also respond better to thyroid augmentation. This article reviews the relationship between thyroid function and mood, and the use of thyroid hormones in the treatment of mood disorders. The impact of gender on these issues is also discussed.

Hormonal changes in the postpartum and implications for postpartum depression

The months following childbirth are a time of heightened vulnerability to depressive mood changes. Because of the abrupt and dramatic changes occurring in hormone levels after delivery, many studies have examined the role of hormonal factors in postpartum depression. The authors review the literature on potential hormonal etiologies in postpartum depression, in particular for progesterone, estrogen, prolactin, cortisol, oxytocin, thyroid, and vasopressin. While evidence for an etiologic role is lacking for most hormones, changes in certain hormonal axes may contribute to depressive mood changes in some women following childbirth.

The relationship between maternity blues and thyroid dysfunction

OBJECTIVE

To investigate whether there is evidence of thyroid dysfunction in women with maternity blues.

METHODS

Twenty women with maternity blues and 20 age-matched normal controls were enrolled in our study. The serum levels of 6 kinds of thyroid hormones, cortisol, and prolactin (PRL) of the 2 groups were compared, and obstetric variables were recorded for each subject. In addition, significant variables correlating with the development of maternity blues were determined by stepwise regression analysis.

RESULTS

The serum-free triiodothyronine (FT3) level at 5 days puerperium was lower in the maternity blues group (p < 0.05) than in the control group. In the maternity blues group, the FT3 level at 5 days puerperium was lower than that at 37 weeks of pregnancy and at 1 month puerperium (p < 0.05). The reverse T3 levels and TSH levels at 5 days postpartum were higher in women with maternity blues than among the controls (p < 0.05). The proportion of primiparous women was higher in the maternity blues group (p < 0.01). Stepwise regression analysis revealed that the low FT3 level and primiparity were significantly correlated with the development of maternity blues (R2 = 0.281, p < 0.001).

CONCLUSION

Thyroid dysfunction might be associated with the development of maternity blues.

Cardiff puerperal mood and hormone study. III. Postnatal depression at 5 to 6 weeks postpartum, and its hormonal correlates across the peripartum period

BACKGROUND

We assessed associations of mood at 5-6 weeks postpartum with peripartum saliva cortisol and progesterone profiles.

METHOD

A prospective study involved 120 primiparous women free of major marital, socioeconomic and health problems, who collected saliva twice daily from 2 weeks before delivery to day 35 postpartum. This allowed intensive characterisation of cortisol and progesterone profiles. At the conclusion of the study, mood was assessed according to standard criteria.

RESULTS

Seven women developed major depression according to DSM-III-R criteria. No associations emerged between progesterone and mood at 5 to 6 weeks. Lower levels of evening cortisol in the immediate peripartum period, were associated with postnatal depression.

CONCLUSION

The study provides no support for the treatment strategy of progesterone augmentation following delivery, as a prophylactic against postnatal depression. The HPA axis and its associations with postnatal mood warrants further investigation.