Risk factors for early postpartum depressive symptoms

The effect of music played to new birth mothers on postpartum blues: A randomized controlled trial

BACKGROUND

Postpartum blues/postpartum maternal blues is a psychological disorder experienced by mothers with symptoms of postpartum sadness, easy crying, easy anxiety, sensitivity, indecisiveness. The study aimed to examine the effect of music played on newly delivered mothers on postpartum blues.

METHODS

A prospective, two-arm, randomized controlled study was conducted on n = 82 (41 = control, 41 = music group) mothers who gave birth at term in Trakya University Health Research and Application Center Maternity Service between May and December 2023. The research data were collected through the Personal Information Form, Stein Blues Scale (SBS), and Edinburgh Postpartum Depression Scale (EPDS). The scales used in the study were evaluated four times: postoperative 0-3 h, 12th, 24th, and 36th hours.

RESULTS

The postoperative 0-3 h SBS test median of the new mothers in the music group was 19.00, and the 36th hours test median was 2.00, while the postoperative 0-3 h SBS test median of the control group was 21.00, and the 36th hour test median was 13.00. The postoperative 0-3 h EPDS test median of the new mothers in the music group was 22.00, and the 36th hours test median was 0.00, while the postoperative 0-3 h EPDS test median of the control group was 26.00, and the 36th hours test median was 10.00. A significant difference was found in the 12th, 24th, and 36th hours (p < .001). A statistically significant high positive correlation was found between EPDS and SBS in the 12th, 24th, and 36th hours (p < .001).

CONCLUSIONS

In the study, it was found that music played to newly delivered mothers reduced postpartum blues and depression levels.

REGISTRATION

The submission date for a clinical trial protocol is prior to completing participant recruitment and for a systematic review, prior to completing full paper screening. NCT06252155.

The pharmacotherapeutic management of premenstrual dysphoric disorder

INTRODUCTION

Premenstrual dysphoric disorder (PMDD) is a prevalent psychiatric condition associated with substantial mental distress, impaired psychosocial functioning, high rates of co-morbid psychiatric conditions, and elevated risk of suicide.

AREAS COVERED

We provide an update on epidemiology, pathophysiology, clinical presentation, and diagnosis of PMDD, with a focus on the pharmacological management of this condition.

EXPERT OPINION

Given the high rates of false positives from retrospective assessments, prospective daily symptom monitoring for a minimal of two symptomatic menstrual cycles is critical to accurately confirm (or rule out) the diagnosis of PMDD. Serotonin-based antidepressants are well-established first-line treatments of PMDD. Second-line treatment includes the use of combined, monophasic oral contraceptives. In mild to moderate cases, independent meta-analyses have shown efficacy of Chasteberry extract (Vitex agnus cactus). Preliminary results with compounds blocking the synthesis of allopregnanolone are promising.

Risk factors of postpartum depression and depressive symptoms: umbrella review of current evidence from systematic reviews and meta-analyses of observational studies

BACKGROUND

Evidence on risk factors for postpartum depression (PPD) are fragmented and inconsistent.

AIMS

To assess the strength and credibility of evidence on risk factors of PPD, ranking them based on the umbrella review methodology.

METHOD

Databases were searched until 1 December 2020, for systematic reviews and meta-analyses of observational studies. Two reviewers assessed quality, credibility of associations according to umbrella review criteria (URC) and evidence certainty according to Grading of Recommendations-Assessment-Development-Evaluations criteria.

RESULTS

Including 185 observational studies (n = 3 272 093) from 11 systematic reviews, the association between premenstrual syndrome and PPD was the strongest (highly suggestive: odds ratio 2.20, 95%CI 1.81-2.68), followed by violent experiences (highly suggestive: odds ratio (OR) = 2.07, 95%CI 1.70-2.50) and unintended pregnancy (highly suggestive: OR=1.53, 95%CI 1.35-1.75). Following URC, the association was suggestive for Caesarean section (OR = 1.29, 95%CI 1.17-1.43), gestational diabetes (OR = 1.60, 95%CI 1.25-2.06) and 5-HTTPRL polymorphism (OR = 0.70, 95%CI 0.57-0.86); and weak for preterm delivery (OR = 2.12, 95%CI 1.43-3.14), anaemia during pregnancy (OR = 1.47, 95%CI 1.17-1.84), vitamin D deficiency (OR = 3.67, 95%CI 1.72-7.85) and postpartum anaemia (OR = 1.75, 95%CI 1.18-2.60). No significant associations were found for medically assisted conception and intra-labour epidural analgesia. No association was rated as 'convincing evidence'. According to GRADE, the certainty of the evidence was low for Caesarean section, preterm delivery, 5-HTTLPR polymorphism and anaemia during pregnancy, and 'very low' for remaining factors.

CONCLUSIONS

The most robust risk factors of PDD were premenstrual syndrome, violent experiences and unintended pregnancy. These results should be integrated in clinical algorithms to assess the risk of PPD.

Prospective Investigation of Glutamate Levels and Percentage Gray Matter in the Medial Prefrontal Cortex in Females at Risk for Postpartum Depression

BACKGROUND

The substantial female hormone fluctuations associated with pregnancy and postpartum have been linked to a greater risk of developing depressive symptoms, particularly in high-risk women (HRW), i.e. those with histories of mood sensitivity to female hormone fluctuations. We have shown that glutamate (Glu) levels in the medial prefrontal cortex (MPFC) decrease during perimenopause, a period of increased risk of developing a major depressive episode. Our team has also demonstrated that percentage gray matter (%GM), another neural correlate of maternal brain health, decreases in the MPFC during pregnancy.

OBJECTIVE

To investigate MPFC Glu levels and %GM from late pregnancy up to 7 weeks postpartum in HRW and healthy pregnant women (HPW).

METHODS

Single-voxel spectra were acquired from the MPFC of 41 HPW and 22 HRW using 3- Tesla in vivo proton magnetic resonance spectroscopy at five different time points.

RESULTS

We observed a statistically significant interaction between time and group for the metabolite Glu, with Glu levels being lower for HRW during pregnancy and early postpartum (p<0.05). MPFC %GM was initially lower during pregnancy and then significantly increased over time in both groups (p<0.01).

CONCLUSION

This investigation suggests that the vulnerability towards PPD is associated with unique fluctuations of MPFC Glu levels during pregnancy and early postpartum period. Our results also suggest that the decline in MPFC %GM associated with pregnancy seems to progressively recover over time. Further investigations are needed to determine the specific role that female hormones play on the physiological changes in %GM during pregnancy and postpartum.

Association between labor and delivery pain and postpartum pain with symptoms and clinical diagnosis of postpartum depression in patients with overweight and obesity

Purpose

Childbirth pain has been associated with the risk for postpartum depression. However, existing studies have been limited by the use of depression screening tools as outcomes, and none to date have used a structured clinical interview for DSM-V (SCID), which is considered the gold standard for psychiatric diagnoses. This study aimed to quantify the relationships between labor and postpartum pain and postpartum depression diagnosis detected by SCID, as well as depression symptoms detected by the Center for Epidemiological Studies Depression Scale (CESD) screening tool, among a high-risk cohort.

Methods

The study was a secondary analysis of a prospective observational study of a cohort of women enriched for high risk for depression, i.e., pregnant women originally enrolled in a prospective study investigating factors leading to excessive gestational weight gain. Subjects were assessed prospectively for depression using both SCID and CESD at the third trimester and at 6 months postpartum. Overweight and obesity were defined as pre-gravid body mass index (BMI) ≥ 25 kg/m2. Both vaginal and cesarean deliveries were included in the cohort. Pain scores (0–10 numeric rating scale) during childbirth and after delivery were correlated with CESD and SCID. Propensity score matching was performed with propensity groups defined as those with low–moderate postpartum pain and those with high postpartum pain. The relationships between pain measures and 6-month postpartum depression diagnosis by SCID, and between pain measures and 6-month postpartum depression symptoms by CESD, were assessed by unweighted logistic regression and by logistic regression weighted by propensity score derived by average treatment effect (ATE) adjusted for baseline covariates.

Results

There were 237 subjects in the cohort for analysis. Labor and postpartum pain were not associated with depression diagnosis by SCID at 6 months postpartum. However, postpartum pain, but not labor pain, was associated with depressive symptoms on the CESD at 6 months postpartum. Women with higher maximum postpartum pain scores had significantly higher odds of developing clinically significant postpartum depressive symptoms at 6 months, compared to those with lower pain scores in the unweighted model (OR: 1.3, 95% CI 1.0, 1.5; P = 0.005) and ATE-weighted models (OR: 1.2, 95% CI 1.0, 1.5; P = 0.03). Consistent with prior work, SCID and CESD were strongly associated, and 92.9% (13/14) of participants with postpartum depression diagnosis by 6-month SCID also showed high CESD symptomology, P < 0.0001).

Conclusions

Although labor and postpartum pain were not associated with clinical diagnosis of depression (SCID) at 6 months postpartum, postpartum pain was linked to 6-month postpartum depression symptoms. Depressive symptoms are more likely to be exhibited in women with higher postpartum pain, potentially reflecting poorer birth recovery. The contribution of postpartum pain and depressive symptoms to overall patterns of poor recovery after childbirth should be assessed further.

Emergency cesarean section is a risk factor for depressive symptoms when breastfeeding is limited

OBJECTIVE

Previous studies indicated associations between cesarean section (CS), breastfeeding, and depressive symptoms. There is, however, little research integrating these variables into one model to analyze their interrelations. The aim of this observational prospective longitudinal study is to examine whether the effect of CS on postpartum depressive symptoms is mediated by difficulties with breastfeeding.

METHODS

The participants were recruited in 5 maternity hospitals during their prenatal medical check-ups. Breastfeeding status was self-reported by the mothers six weeks postpartum. Screening for depressive symptoms was performed at six weeks (N = 404) and nine months (N = 234) postpartum using the Edinburgh Postnatal Depression Scale. Path analysis was used to model the relations between CS, breastfeeding, and depressive symptoms.

RESULTS

No direct effects of CS on depressive symptoms at six weeks or nine months postpartum were found. CS was associated with a lower probability of exclusive breastfeeding, which was, in turn, associated with higher levels of depressive symptoms six weeks postpartum. The analysis stratified by type of CS revealed that the effect on breastfeeding only occurred with emergency, not planned, CS. The effect of CS on breastfeeding was noticeably stronger in women without versus with a history of depression.

CONCLUSION

Emergency CS predicts breastfeeding difficulties, which are, in turn, associated with higher levels of depressive symptoms. Support should be provided to mothers with emergency CS and breastfeeding problems to reduce the risk of postpartum depressive symptoms in the early postpartum period.

Regional Differences in Various Risk Factors for Postpartum Depression: Applying Mixed Models to the PRAMS Dataset

Purpose: The purpose of this study was to assess the association between various risk factors with postpartum depression severity using a large dataset that included variables such as previous mental health status, social factors, societal factors, health care access, and other state-wide or region-specific variables.

Methods: We obtained the most recently available (2016–2017) dataset from the Pregnancy Risk Assessment Monitoring System (PRAMS), which is a dataset compiled by the Centers for Disease Control (CDC) that collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy from over 73,000 women in 39 states. We utilized a hierarchical linear model to analyze the data across various levels, with a symptom severity scale (0–8) as the dependent variable.

Results: Of the 21 variables included in the final model, nine variables were statistically significant predictors of symptom severity. Statistically significant predictors of increased postpartum depression symptom severity included previous depression diagnosis and depression symptoms during pregnancy, baby not residing with mother, unintentional pregnancy, women with less than a high school degree and more than a college degree, Women Infants Children (WIC) enrollment, and married women. In contrast to these other factors, attendance at a postpartum follow up appointment was associated with significantly increased symptom severity. Age revealed an inverted curve in predicting postpartum symptom severity.

Conclusions: There was no significant difference in symptom severity scores across the 39 participating states. Most notably, postpartum depression symptom severity was associated with previous depression diagnosis and previous symptom severity, but our results also reveal novel social and education factors that contribute to the support and well-being of the mother and child.

Examining early structural and functional brain alterations in postpartum depression through multimodal neuroimaging

Postpartum depression (PPD) affects approximately 1 in 10 women after childbirth. A thorough understanding of a preexisting vulnerability to PPD will likely aid the early detection and treatment of PPD. Using a within-sample association, the study examined whether the brain's structural and functional alterations predict the onset of depression. 157 euthymic postpartum women were subjected to a multimodal MRI scan within the first 6 days of childbirth and were followed up for 12 weeks. Based on a clinical interview 12 weeks postpartum, participants were classified as mentally healthy or having either PPD or adjustment disorder (AD). Voxel-based morphometry and resting-state functional connectivity comparisons were performed between the three groups. 13.4% of women in our study developed PPD (n = 21) and 12.1% (n = 19) adjustment disorder (AD). The risk factors for PPD were a psychiatric history and the experience and severity of baby blues and the history of premenstrual syndrome. Despite the different risk profiles, no differences between the PPD, AD and control group were apparent based on structural and functional neuroimaging data immediately after childbirth. At 12 weeks postpartum, a significant association was observed between Integrated Local Correlation (LCor) and the Edinburgh Postnatal Depression Score (EPDS). Our findings do not support the notion that the brain's structural and resting-state functional alterations, if present, can be used as an early biomarker of PPD or AD. However, effects may become apparent if continuous measures of symptom severity are chosen.

Oxytocin and postpartum depression: A systematic review

Postpartum depression (PPD) is a significant mental health concern, especially for women in vulnerable populations. Oxytocin (OT), a hormone essential for a variety of maternal tasks, including labor, lactation, and infant bonding, has also been hypothesized to have a role in postpartum depression. Women are routinely given synthetic oxytocin to induce or augment labor and to prevent postpartum hemorrhage. The aim of this study was to review the quality and reliability of literature that examines potential relationships between OT and PPD to determine if there is sufficient data to reliably assess the strength of these relationships. We conducted a literature search in December of 2018 using five databases (PubMed, Web of Science, Embase, PsycInfo, and CINAHL). Eligible studies were identified, selected, and appraised using the Newcastle-Ottawa quality assessment scale and Cochrane Collaboration's tool for assessing risk of bias, as appropriate. Sixteen studies were included in the analysis and broken into two categories: correlations of endogenous OT with PPD and administration of synthetic OT with PPD. Depressive symptoms were largely measured using the Edinburgh Postnatal Depression Scale. OT levels were predominately measured in plasma, though there were differences in laboratory methodology and control of confounders (primarily breast feeding). Of the twelve studies focused on endogenous oxytocin, eight studies suggested an inverse relationship between plasma OT levels and depressive symptoms. We are not able to draw any conclusions regarding the relationship between intravenous synthetic oxytocin and postpartum depression based on current evidence due to the heterogeneity and small number of studies (n = 4). Considering limitations of the current literature and the current clinical prevalence of synthetic OT administration, we strongly recommend that rigorous studies examining the effects of synthetic OT exposure on PPD should be performed as well as continued work in defining the relationship between endogenous OT and PPD.

Machine Learning-Based Predictive Modeling of Postpartum Depression

Postpartum depression is a serious health issue beyond the mental health problems that affect mothers after childbirth. There are no predictive tools available to screen postpartum depression that also allow early interventions. We aimed to develop predictive models for postpartum depression using machine learning (ML) approaches. We performed a retrospective cohort study using data from the Pregnancy Risk Assessment Monitoring System 2012–2013 with 28,755 records (3339 postpartum depression and 25,416 normal cases). The imbalance between the two groups was addressed by a balanced resampling using both random down-sampling and the synthetic minority over-sampling technique. Nine different ML algorithms, including random forest (RF), stochastic gradient boosting, support vector machines (SVM), recursive partitioning and regression trees, naïve Bayes, k-nearest neighbor (kNN), logistic regression, and neural network, were employed with 10-fold cross-validation to evaluate the models. The overall classification accuracies of the nine models ranged from 0.650 (kNN) to 0.791 (RF). The RF method achieved the highest area under the receiver-operating-characteristic curve (AUC) value of 0.884, followed by SVM, which achieved the second-best performance with an AUC value of 0.864. Predictive modeling developed using ML-approaches may thus be used as a prediction (screening) tool for postpartum depression in future studies.

Longitudinal assessment of symptoms of postpartum mood disorder in women with and without a history of depression

The main objective of the present study was to report the incidence, recurrence, prevalence, and course of depressive symptoms during the transition from late pregnancy to the postpartum period in healthy women with and without a history of depression. The study also aimed to examine the predictive value of a history of premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) for peripartum depressive symptoms. A sample of 687 healthy women with (n = 192) and without (n = 495) a history of depression were included in the present analyses. Maternal depressive symptoms were assessed during late pregnancy, 1-2 weeks postpartum, and 4-6 weeks postpartum using the German version of the Edinburgh Postnatal Depression Scale. PMS/PMDD was assessed retrospectively using the German version of the Premenstrual Symptoms Screening Tool. Women with a history of depression were twice more likely to show peripartum depressive symptoms than women without a history of depression. A history of symptoms of PMS/PMDD prior to the current pregnancy was associated with increased odds of peripartum depressive symptoms (p values < .05). Peripartum depressive symptoms are highly prevalent, especially in women with a history of depression and co-existing symptoms of PMS/PMDD. Screening for depression in the antenatal period is highly recommended, particularly for individuals with previous PMS/PMDD or a history of depression.

Early detection of mental illness for women suffering high-risk pregnancies: an explorative study on self-perceived burden during pregnancy and early postpartum depressive symptoms among Chinese women hospitalized with threatened preterm labour

BACKGROUND

The mental health of pregnant women, particularly those with elevated risks, has been an issue of global concern. Thus far, few studies have addressed the mental health of pregnant women with threatened preterm labour (TPL). This study investigated the prevalence of self-perceived burden (SPB) among Chinese women hospitalized due to TPL during pregnancy and early postpartum depressive disorders, exploring the effect of SPB and other potential risk factors on the early signs of postpartum depressive disorders.

METHODS

A self-reported survey was conducted in the obstetrics department of Anhui Provincial Hospital, China. Women hospitalized with TPL were approached 1 week after delivery. One hundred fifty women were recruited from January 2017 to December 2017. The Self-Perceived Burden Scale (SPBS) and Edinburgh Postnatal Depression Scale (EPDS) were the main measures. Descriptive statistics, Spearman correlations, and a multiple logistic regression were employed for data analysis.

RESULTS

SPB and early postpartum depressive disorders were commonly experienced by Chinese women hospitalized with TPL, and SPB was positively and significantly correlated with depressive symptoms. A multiple logistic regression analysis revealed that for the women hospitalized with TPL during pregnancy, the emotional aspect of SPB (OR = 1.42, 95% CI = 1.11-1.83, p = 0.006), age (OR = 1.14, 95% CI = 1.02-1.27, p = 0.023), occupation (OR = 3.48, 95% CI = 1.18-10.20, p = 0.023), the history of scarred uterus (OR = 7.96, 95% CI = 1.49-42.48, p = 0.015), the delivery mode of the present birth (OR = 6.19, 95% CI = 1.72-22.30, p = 0.005), and family support during pregnancy (OR = 0.60, 95% CI = 0.45-0.82, p = 0.001) were significant factors predicting early postpartum depressive symptoms.

CONCLUSION

This study indicates that SPB and early postpartum depressive disorders are prevalent mental issues among Chinese women hospitalized with TPL, and that SPB, especially perceived emotional burden, is a strong predictor of early postpartum depressive disorders. Our study suggests the necessity of paying attention to mental health issues, e.g. SPB and postpartum depressive symptoms among hospitalized women with TPL, and providing appropriate interventions at the prenatal stage to prevent adverse consequences.

Relationship between a high Edinburgh Postnatal Depression Scale score and premenstrual syndrome: A prospective, observational study

OBJECTIVE

This study aimed to evaluate whether the Edinburgh Postnatal Depression Scale (EPDS) score predicts the occurrence of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) after delivery.

MATERIALS AND METHODS

The women in this study were registered at 35-36 weeks of pregnancy at Mie University Hospital from 2013 to 2015. We prospectively divided the puerperants into those with an EPDS score ≥9 (the high-EPDS group) and those with an EPDS score <9 (the low-EPDS group) at 1 month postpartum. We compared the incidence rate of severe PMS and PMDD between both groups at 1 year after delivery.

RESULTS

Of 200 registered cases, 178 (89.0%) did not experience severe PMS or PMDD before pregnancy. Among them, 21 were in the high-EPDS group, and 89 in the low-EPDS group. Four of the 21 women (19.0%) in the high-EPDS group and five of the 89 (5.6%) in the low-EPDS group had severe PMS or PMDD at 1 year after delivery. The incidence rate of severe PMS or PMDD in the high-EPDS group was higher than that in the low-EPDS group (p = 0.07).

CONCLUSIONS

The novel finding of this study is that the EPDS may predict the occurrence of severe PMS/PMDD after delivery. The EPDS will contribute to the early detection of these diseases and to improving the quality of life of the patients by allowing treatment initiation at an early stage.

Associations of sociodemographic and clinical factors with perinatal depression among Israeli women: a cross-sectional study

BACKGROUND

Perinatal depression is a common problem that affects about 18% of women worldwide, though the heterogeneity between countries is great. The aims of this study were to assess the prevalence of perinatal depressive symptoms in a national sample of women in Israel, and to investigate associations of these symptoms with demographic, medical and lifestyle factors.

METHODS

The study included all members of Maccabi Health Services, the second largest health maintenance organization in Israel, who filled the Edinburgh Postnatal Depression Scale (EPDS) during 2015-2016. Crude odds ratios (ORs) and adjusted ORs (aORs) are presented for associations of sociodemographic, medical and lifestyle factors with perinatal depressive symptoms, according to a score ≥ 10 on the EPDS.

RESULTS

Of 27,520 women who filled the EPDS, 1346 (4.9%) met the criteria for perinatal depression. In a logistic regression analysis we found the following factors associated with perinatal depression: the use of antidepressant medications (aOR = 2.34, 95% CI 1.94-2.82, P < 0.001 and aOR = 3.44; 95% CI 2.99-3.97, P < 0.001 for ≤3 months and > 3 months respectively), a diagnosis of chronic diabetes mellitus (aOR = 2.04; 95% CI 1.22-3.43, P = 0.007), Arab background (aOR = 2.28; 95% CI 1.82-2.86, P < 0.001), current and past smoking (aOR = 1.62; 95% CI 1.35-1.94, P < 0.001 and aOR = 1.36; 95% CI 1.05-1.76, P = 0.021, respectively), and anaemia (aOR = 1.17; 95% CI 1.04-1.32, P = 0.011). Orthodox Jewish affiliation and residence in the periphery of the country were associated with lower perinatal depression (aOR = 0.48; 95% CI 0.36-0.63, P < 0.001 and aOR = 0.72; 95% CI 0.57-0.92, P = 0.007, respectively).

CONCLUSIONS

The prevalence of perinatal depression in this study was 4.9%. Perinatal depression was associated with a number of demographic, medical and lifestyle factors, including the use of antidepressant medication, chronic diabetes mellitus, Arab background, current or past smoking, and anaemia. These risk factors may help identify women at risk of perinatal depression.

Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations

There is a new appreciation of the perimenopause - defined as the early and late menopause transition stages as well as the early postmenopause - as a window of vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects of hormone therapy; and 5) efficacy of other therapies (eg, psychotherapy, exercise, and natural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women, particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

Role of Estradiol in the Expression of Genes Involved in Serotonin Neurotransmission: Implications for Female Depression

BACKGROUND

In women, changes in estrogen levels may increase the incidence and/or symptomatology of depression and affect the response to antidepressant treatments. Estrogen therapy in females may provide some mood benefits as a single treatment or might augment clinical response to antidepressants that inhibit serotonin reuptake.

OBJECTIVE

We analyzed the mechanisms of estradiol action involved in the regulation of gene expression that modulates serotonin neurotransmission implicated in depression.

METHOD

Publications were identified by a literature search on PubMed.

RESULTS

The participation of estradiol in depression may include regulation of the expression of tryptophan hydroxylase-2, monoamine oxidase A and B, serotonin transporter and serotonin-1A receptor. This effect is mediated by estradiol binding to intracellular estrogen receptor that interacts with estrogen response elements in the promoter sequences of tryptophan hydroxylase-2, serotonin transporter and monoamine oxidase-B. In addition to directly binding deoxyribonucleic acid, estrogen receptor can tether to other transcription factors, including activator protein 1, specificity protein 1, CCAAT/enhancer binding protein β and nuclear factor kappa B to regulate gene promoters that lack estrogen response elements, such as monoamine oxidase-A and serotonin 1A receptor.

CONCLUSION

Estradiol increases tryptophan hydroxylase-2 and serotonin transporter expression and decreases the expression of serotonin 1A receptor and monoamine oxidase A and B through the interaction with its intracellular receptors. The understanding of molecular mechanisms of estradiol regulation on the protein expression that modulates serotonin neurotransmission will be helpful for the development of new and more effective treatment for women with depression.

Depression and Menopause: An Update on Current Knowledge and Clinical Management for this Critical Window

Windows of vulnerability for depression have been associated with increased sensitivity to hormonal changes experienced by some women during the luteal phase, postpartum, and/or menopause. Increased awareness has resulted in greater adoption of screening tools for mood and behavioral changes and tailored therapies. This article discusses study results and controversies surrounding therapies uniquely designed for menopause-related depression.

Obstetric and psychosocial risk factors associated with maternity blues

AIM

To identify risk factors for maternity blues (MB) and to evaluate the impact of obstetric factors on MB prevalence.

MATERIALS AND METHODS

194 mothers have completed the Edinburgh Postnatal Depression Scale (EPDS) 2 days after delivery. Bivariate and multivariate logistic regression models were used to identify the predictors of MB.

RESULTS

57 women (29.4%) were positive at screening. Comparing the two groups, no statistically significant difference was found in age (p = .536), nationality (p = .065) and BMI before pregnancy (p = .224). Interestingly, no significant differences were highlighted in terms of assisted reproduction technology or spontaneous pregnancies and the presence of labor analgesia, while MB was significantly more frequent in case of cesarean section (CS) (p = .035). Statistical differences have been found in previous CS (p = .022), previous voluntary interruption of pregnancy (p = .021), number of previous pregnancies (p = .007), Apgar 5' (p = .026), lower level of education (p = .009), and previous postpartum depression (PPD) (p = .026). A logistic regression analysis was realized according to a multivariate model incorporating all the variables with a p-value ≤.25 in bivariate analysis. In the final model vaginal delivery (OR 0.451, 95% CI [0.224-0.911], p = .026) resulted to be MB protective factor, while a lower level of education (OR 3.657, 95% CI [1.482-9.023], p = .005) as well as previous PPD (OR 4.714, 95% CI [1.273-17.458], p = .020) were identified as independent risk factors.

CONCLUSION

This study showed that a lower education level and a previous PPD resulted to be important risk factors for MB development, while natural delivery was revealed as a protective factor. These results could be used to develop a better and more accurate prevention program after delivery.

Postpartum depression - a medical or a social problem?

Objective: The aim of the study was to identify a group of women needed psychological support after delivery by identifying the medical and social factors that may influence the emotional changes during the postpartum period.Materials and method: A group of 835 pregnant women in second, third trimester of pregnancy, and during the postpartum period completed the Edinburgh Postnatal Depression Scale and the questionnaire consisting of difficulties that might occur in the four life fields: practical, family, emotional, and physical. The calculations have been carried out with the statistical package Statistica v10 and Cytel Studio v 9.0.0. At the Faculty of Information Science and Statistics of the Poznań University of Medical Sciences.Results: There is a series of medical and social risk factors potentially increasing the risk of postpartum depression, such as psychiatric disorders in the past, difficulties in the professional work, unsatisfactory relationship with partner, and others.Conclusions: Having selected a group of women with risk factors it seems reasonable to apply the Edinburgh Postnatal Depression Scale.

Omega-3 polyunsaturated fatty acid supplementation in prevention and treatment of maternal depression: Putative mechanism and recommendation

BACKGROUND

Women are vulnerable to depression during their childbearing years, and giving birth to a child precipitates postpartum depression (PPD) in some women. This review focuses on comparing the effectiveness of omega-3 polyunsaturated fatty acid supplementation on depression during pregnancy or PPD after childbirth.

METHODS

MEDLINE, PubMed, PsycINFO, and the Cochrane Collaboration Registry of Controlled Trials etc. through July 2017 were searched. Studies of dietary intake and plasma and/or milk levels of omega-3 fatty acids and trials of benefits and effects of omega-3 fatty acids supplements on pregnant or postpartum women with depression were specifically selected.

RESULTS

Omega-3 fatty acid deficiency, due to inadequate intake, fast depletion during pregnancy and lactation, is one of the risk factors of PPD. Associations between neuroinflammation (elevated pro-inflammatory cytokines) and aberrant neurotransmission (low serotonergic transmission activity) and risk of PPD have also been reported by numerous studies. Supplementation with eicosapentaenoic acid (EPA)-rich oil can effectively reduce depression during pregnancy and PPD after childbirth. Long term treatment with docosahexaenoic acid (DHA)-rich oil can be effective in reducing the risk of PPD in healthy women, but not in lactating women. Supplementation of DHA-rich oil to women begun at pregnancy and continued after childbirth exerts no beneficial effect on depression.

CONCLUSIONS

Dietary supplementation with omega-3 fatty acids rich in EPA during pregnancy or postpartum reduces some symptoms associated with depression. DHA supplementation to healthy pregnant women can also reduce the risk of PPD.

Women With Mental Illness Seeking Assisted Reproduction Considerations in Ethical Candidate Selection

PURPOSE OF REVIEW

This review aims to provide guidance to clinicians facing requests for assisted reproduction from women with mental illness.

RECENT FINDINGS

The paper explores the clinical and safety aspects of initiating fertility treatment in this context, including the use of psychotropic medication and the risk of untreated psychiatric mood or psychotic disorders. It also presents the ethical considerations involved in candidate selection, including treating similar cases equitably to avoid biased decisions based solely on "gut-feelings," respect for women's reproductive autonomy, and an effort to protect patients and prospective fetuses/children from harm by employing optimal strategies regarding medication and psychosocial support. Clinicians ought to be informed regarding recent evidence related to the safety and efficacy of psychopharmacologic treatment of women during pregnancy and the post-partum. They should also carry out a thoughtful ethical analysis to ensure minimal violation of women's reproductive autonomy.

Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries

BACKGROUND

Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence.

METHODS

We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence.

FINDINGS

291 studies of 296284 women from 56 countries were identified. The global pooled prevalence of PPD was 17.7% (95% confidence interval: 16.6-18.8%), with significant heterogeneity across nations (Q = 16,823, p = 0.000, I2 = 98%), ranging from 3% (2-5%) in Singapore to 38% (35-41%) in Chile. Nations with significantly higher rates of income inequality (R2 = 41%), maternal mortality (R2 = 19%), infant mortality (R2 = 16%), or women of childbearing age working ≥40 h a week (R2 = 31%) have higher rates of PPD. Together, these factors explain 73% of the national variation in PPD prevalence.

INTERPRETATION

The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

Depression and Menopause: Current Knowledge and Clinical Recommendations for a Critical Window

Depression is a disabling condition, which often leads to significant personal, societal, and economic costs. Windows of vulnerability for depression in women likely are associated with an increased sensitivity experienced by some women to changes in the hormonal milieu that occur during the luteal phase of their cycles, during the postpartum period, and/or during the menopause transition. The controversy surrounding a menopause-related depression has been fueled by conflicting methodologies used to characterize reproductive staging or assess psychiatric conditions during midlife years.

Screening mixed depression and bipolarity in the postpartum period at a primary health care center

INTRODUCTION

Mixed depression is a clinical condition accompanied by the symptoms of (hypo)mania and is considered to be a predictor for bipolar disorder. Compared to pure major depression, mixed depression is worse in progress. There are limited data on the prevalence of mixed depression since it is a relatively new entity. Therefore, the present study aimed to investigate the prevalence of mixed depression during the postpartum period which is risky for mood disorders.

METHODS

The study included 63 postpartum women. The participants were administered Beck Depression Scale, Edinburgh Postnatal Depression Scale (EPDS), Mood Disorders Questionnaire (MDQ), and Modified Hypomania Symptom Checklist-32 (mHCL-32).

RESULTS

The MDQ scores of the women with expected depression according to the EPDS cut-off scores, were significantly higher than the women with lower EPDS scores (t=-4.968; p<0.001). The modified hypomania scores were significantly higher in the women with higher depression scores compared to the women under EPDS cut-off scores (t=-4.713; p<0.001). According to the EPDS and BDS results, 27 (42.9%) and 14 (22.2%) women needed additional clinical examination for depression, respectively. In addition, 3 (4.8%) women require additional clinical examination for bipolar disorder. The scores for the first item of MDQ were above the cut-off value in 11 (17.5%) women. According to the mHCL-32 results, 50 (79.4%) women had at least 1 symptom, 45 (71.4%) women had at least 3 symptoms, and 43 (68.3%) women had at least 5 symptoms of mixed depression.

CONCLUSION

Postpartum mixed depression should be promptly diagnosed by using appropriate diagnostic tools, particularly by primary health care physicians. Patients with mixed depression should be closely monitored to avoid manic switch.

Prediction of incidence and bio-psycho-socio-cultural risk factors of post-partum depression immediately after birth in an Iranian population

INTRODUCTION

Post-partum depression (PPD) is the most prevalent mental problem associated with childbirth. The purpose of the present study was to determine the incidence of early PPD and possible relevant risk factors among women attending primary health centers in Mazandaran province, Iran for the first time.

MATERIAL AND METHODS

A longitudinal cohort study was conducted among 2279 eligible women during weeks 32-42 of pregnancy to determine bio-psycho-socio-cultural risk factors of depression at 2 weeks post-partum using the Iranian version of the Edinburgh Postnatal Depression Scale (EPDS). Univariate and hierarchical multiple logistic regression models were used for data analysis.

RESULTS

Among 1,739 mothers whose EPDS scores were ≤ 12 during weeks 32-42 of gestation and at the follow-up study, the cumulative incidence rate of depression was 6.9% (120/1,739) at 2 weeks post-partum. In the multivariate model the factor that predicted depression symptomatology at 2 weeks post-partum was having psychiatric distress in pregnancy based on the General Health Questionnaire (GHQ) (OR = 1.06, (95% CI: 1.04-1.09), p = 0.001). The risk of PPD also lower in those with sufficient parenting skills (OR = 0.78 (95% CI: 0.69-0.88), p = 0.001), increased marital satisfaction (OR = 0.94 (95% CI: 0.9-0.99), p = 0.03), increased frequency of practicing rituals (OR = 0.94 (95% CI: 0.89-0.99), p = 0.004) and in those whose husbands had better education (OR = 0.03 (95% CI: 0.88-0.99), p = 0.04).

CONCLUSIONS

The findings indicated that a combination of demographic, sociological, psychological and cultural risk factors can make mothers vulnerable to PPD.

Elevated levels of Hs-CRP and IL-6 after delivery are associated with depression during the 6 months post partum

The objective of this study is to determine whether inflammatory markers (high-sensitivity C-reactive protein (Hs-CRP) and interleukin (IL)-6) early in the postpartum period contribute to the development of postpartum depression (PPD). From 4 May 2014 to 30 June 2014, all eligible women not on medication for depression giving birth at the Beijing Chao-Yang hospital were consecutively recruited and followed up for 6 months. Depression symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS), and inflammatory biomarkers (Hs-CRP and IL-6) were tested. During the study period, 296 women were enrolled and completed follow-up. In these women, 45 (15.2%) were considered as meeting the criteria for PPD. Serum levels of Hs-CRP and IL-6 in women with PPD were significantly higher than those without PPD (all P<0.0001). Receiver operating characteristics to predict PPD demonstrated areas under the curve of IL-6 of 0.861 (95% confidence interval (CI), 0.801-0.922), which was superior to Hs-CRP (0.837 (95% CI, 0.781-0.894), P<0.01). In multivariate logistic regression analysis, IL-6 and Hs-CRP were independent predictors of PPD. The present study demonstrates a strong relationship between elevated serum Hs-CRP and IL-6 levels at admission and the development of PPD within 6 months.

Serum BDNF concentration after delivery is associated with development of postpartum depression: A 3-month follow up study

BACKGROUND

Our aim was to determine whether there is a relationship between serum brain-derived neurotrophic factor (BDNF) and postpartum depression (PPD) in a cohort Chinese population.

METHODS

From May 1, 2014, to September 30, 2014, all eligible women not on medication for depression giving birth at the Fourth Affiliated Hospital of Harbin Medical University were consecutively recruited and followed up for 3 months. At 3 months postpartum, women were screened for depression using the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome measure was an EPDS score of > or =12. Enzyme-linked immunosorbent assay (ELISA) was used to measure serum levels of BDNF at admission. Multivariate analyses were performed using logistic regression models.

RESULTS

During the study period, 340 women were enrolled and completed follow-up. In those women, 37 women (10.9%) were considered as meeting criteria for PPD. Serum BDNF levels in women without PPD were significantly higher than those in women with PPD (P<0.0001). Based on the ROC curve, the optimal cutoff value of serum BDNF levels as an indicator for screening of PPD was estimated to be 12.0ng/ml, which yielded a sensitivity of 82.8% and a specificity of 72.6%, with the area under the curve at 0.809 (95%CI, 0.731-0.887). In multivariate analysis, there was an increased risk of PPD associated with BDNF levels ≤12.0ng/ml (OR 7.243, 95% CI: 3.883-12.746; P<0.0001) after adjusting for possible confounders.

CONCLUSION

The present study demonstrates a strong relationship between reduced serum BDNF levels at admission and the development of PPD within the 3 months.

Disturbed Sleep and Postpartum Depression

The perinatal period introduces a myriad of changes. One important but often overlooked change is an increased reporting of sleep disturbance. Although casually regarded as a consequence of pregnancy or postpartum, there is emerging evidence implicating significant sleep disturbance, characterized by insomnia symptoms and/or poor sleep quality, with adverse outcomes, such as an increase in depressive symptomatology or the development postpartum depression (PPD). Significant consequences may arise as a result including issues with maternal-infant bonding, effective care for the infant, and behavioral or emotional difficulties in the infant. This review discusses the relevant literature as to how disturbed sleep during pregnancy as well as in the postpartum may increase the risk for PPD.

History of postpartum depression in a clinic-based sample of women with premenstrual dysphoric disorder

OBJECTIVE

Overlapping comorbidities between premenstrual dysphoric disorder (PMDD) and postpartum depression (PPD) suggest that these disorders represent a continuum of vulnerability with shared pathophysiology. We report the past histories of PPD (and other Axis I psychiatric illnesses) in a clinic-based sample of women meeting criteria for PMDD.

METHODS

215 women, ages 19 to 51 years, who attended the National Institute of Mental Health Mood Disorders Clinic between 1988 and 2013 seeking treatment for PMDD and in whom we confirmed the diagnosis of PMDD (DSM-IV), were identified. All were administered the Structured Clinical Interview for DSM-III-R or -IV. The frequency of PPD (major or minor) was established in the subgroup of women (n = 137) who had delivered at least 1 child.

RESULTS

Ninety-three women (43.3%) had a past history of a mood disorder (ie, either major [n = 67; 31.2%] or minor [n = 10; 4.7%] depression or PPD [n = 16; 7.4%; 11.7% of parous women]). Nine of the 16 women with PMDD and a past PPD had either a past major depressive episode (MDE) or subsyndromal anxiety disorder. Thirty-three women (15.3%) had a past history of an Axis I anxiety disorder. A total of 40 women (18.6%) met criteria for past alcohol or drug abuse, 3 (1.4%) met criteria for bulimia nervosa, and 2 (0.9%) met criteria for anorexia nervosa.

CONCLUSIONS

Our data demonstrate that PMDD and PPD do not frequently co-occur. These data do not suggest that PMDD and PPD share similar pathophysiology beyond being ovarian-steroid-triggered mood disorders. The high comorbidity of past MDE could contribute to the increased risk both for future MDE and for PPD in some women with PMDD.

Impact of childhood trauma on postpartum depression: a prospective study

Studies on the impact of childhood trauma on postpartum depression show inconsistencies and methodological limitations. The present study examines the effect of childhood trauma on depression 12 and 24 weeks after childbirth, while controlling for history of depression, depression symptoms during pregnancy and type D personality. During the third trimester of pregnancy, 210 women completed self-report questionnaires assessing depression (current and/or past episodes), childhood trauma and type D personality, of whom 187 participated in the postpartum follow-up, with depression symptoms being reassessed at 12 and 24 weeks after delivery with three depression outcome measures. Eventually, 183 participants were retained for analysis. Results indicated no predictive value of childhood trauma on postpartum depression in the univariate analyses, nor after controlling for previous depression, depression symptoms during pregnancy and type D personality. However, past depression and depression symptoms during pregnancy did independently and convincingly predict postpartum depression, especially at 12 weeks and to a lesser extent at 24 weeks following childbirth. Overall, we found no significant association between childhood trauma and postpartum depression. Past depression and depression symptoms during pregnancy are more relevant factors to assess before childbirth.

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.

Bipolar Depression: Pregnancy, Postpartum, and Lactation

Medication management of bipolar depression in pregnancy and lactation is best done by assessing each patient's and family's needs in detail. Keeping pregnant patients as psychiatrically stable as possible is the most important principle for clinicians. Unfortunately, there is no risk-free situation for patients with psychiatric illness. This is often the most difficult and hard to accept reality for these patients, families, and clinicians. Clinicians serve these patients best by being as transparent as possible about the risk/benefit analysis of each patient's situation with the realization that ultimately the decisions are made by the patient and family.

Delineating the Association between Heavy Postpartum Haemorrhage and Postpartum Depression

OBJECTIVES

To explore the association between postpartum haemorrhage (PPH) and postpartum depression (PPD), taking into account the role of postpartum anaemia, delivery experience and psychiatric history.

METHODS

A nested cohort study (n = 446), based on two population-based cohorts in Uppsala, Sweden. Exposed individuals were defined as having a bleeding of ≥1000 ml (n = 196) at delivery, and non-exposed individuals as having bleeding of <650 ml (n = 250). Logistic regression models with PPD symptoms (Edinburgh Postnatal Depression scale (EPDS) score ≥ 12) as the outcome variable and PPH, anaemia, experience of delivery, mood during pregnancy and other confounders as exposure variables were undertaken. Path analysis using Structural Equation Modeling was also conducted.

RESULTS

There was no association between PPH and PPD symptoms. A positive association was shown between anaemia at discharge from the maternity ward and the development of PPD symptoms, even after controlling for plausible confounders (OR = 2.29, 95%CI = 1.15-4.58). Path analysis revealed significant roles for anaemia at discharge, negative self-reported delivery experience, depressed mood during pregnancy and postpartum stressors in increasing the risk for PPD.

CONCLUSION

This study proposes important roles for postpartum anaemia, negative experience of delivery and mood during pregnancy in explaining the development of depressive symptoms after PPH.

Sleep and postpartum depression

PURPOSE OF REVIEW

The perinatal period introduces a myriad of changes. One important but often overlooked change is the increased risk for sleep disturbance. Although casually regarded as a consequence of pregnancy or postpartum, there is emerging evidence to suggest that women with significant sleep disturbance, characterized by insomnia symptoms and/or poor sleep quality, are more likely to report an increase in depressive symptomatology or develop postpartum depression (PPD). Significant consequences may arise as a result including issues with maternal-infant bonding, effective care for the infant and behavioral or emotional difficulties in the infant. This review discusses the relevant literature as to how disturbed sleep during pregnancy as well as in the postpartum may increase the risk for PPD.

RECENT FINDINGS

Symptoms of insomnia and poor sleep quality are independently associated with greater depressive symptoms across pregnancy and throughout postpartum. Likewise, both can negatively impact the ability to mother effectively.

SUMMARY

The presence of insomnia or sleep disturbance during the perinatal period is a risk factor for depressive symptoms. Women with depression are at an increased risk of developing sleep disturbance thereby increasing depressive symptomatology. This bidirectional and additive relationship needs more clinical attention as both sleep disturbance and depression are noted risk factors for adverse pregnancy outcomes.

Clinical features of and risk factors for major depression with history of postpartum episodes in Han Chinese women: A retrospective study

BACKGROUND

We sought to investigate the clinical features of and risk factors for recurrent major depression (MD) with history of postpartum episodes (PPD) in Han Chinese women and the differences between first-onset postpartum MD (MD that has its first lifetime depressive episode in the postpartum period) and first-onset non-postpartum MD (MD with history of PPD and has its first lifetime depressive episode in a period other than postpartum).

METHODS

Data were derived from the China, Oxford and Virginia Commonwealth University Experimental Research on Genetic Epidemiology (CONVERGE) study (N=6017 cases) and analyzed in two steps. We first examined the clinical features of and risk factors for MD patients with (N=981) or without (N=4410) a history of PPD. We then compared the differences between first-onset postpartum MD (N=583) and first-onset non-postpartum MD (N=398) in those with a history of PPD. Linear, logistic and multinomial logistic models were employed to measure the associations.

RESULTS

A history of PPD was associated with more guilt feelings, greater psychiatric comorbidity, higher neuroticism, earlier onset and more chronicity (OR 0.2-2.8). Severe premenstrual symptoms (PMS) and more childbirths increased the risk of PPD, as did a family history of MD, childhood sexual abuse, stressful life events and lack of social support (OR 1.1-1.3). In the MD with history of PPD subsample, first-onset postpartum MD was associated with fewer recurrent major depressive episodes, less psychiatric comorbidity, lower neuroticism, less severe PMS and fewer disagreements with their husbands (OR 0.5-0.8), but more childbirths (OR 1.2).

LIMITATIONS

Data were obtained retrospectively through interview and recall bias may have affected the results.

CONCLUSIONS

MD with history of PPD in Han Chinese women is typically chronic and severe, with particular risk factors including severe PMS and more childbirths. First-onset postpartum MD and first-onset non-postpartum MD can be partly differentiated by their clinical features and risk factors, but are not clearly distinctive.

Psychiatric support for mothers in the Neonatal Intensive Care Unit

OBJECTIVE

This study describes mental health treatment and follow-up for mothers of infants in a Neonatal Intensive Care Unit (NICU).

STUDY DESIGN

Data were collected retrospectively about 204 mothers referred to a Level 3 NICU Psychiatric Consult Liaison Team over 2 years. This included medical, demographic and treatment information about both mother and infant.

RESULT

Most mothers (69%) were referred within a week of birth, and 100 (49%) of the referred mothers received a psychiatric diagnosis. Psychiatric follow-up was recommended for 13% on leaving the NICU and additional follow-up referrals were made for another 16%. Mothers with more than one initial reason for referral, a past psychiatric history, receiving therapeutic services, receiving a psychiatric diagnosis and receiving pharmacotherapy were all significantly more likely to have follow-up recommended on discharge.

CONCLUSION

Approximately one-sixth of mothers in the NICU were referred, a large proportion received a psychiatric diagnosis, and over a quarter required follow-up after discharge, indicating the importance of the service.

Psychiatric consultation to the postpartum mother

The immediate postpartum period is a time of acute vulnerability to mental illness, which presents unique challenges for the psychiatric consultant. Because the postpartum hospital stay is typically brief, the consultant must have a working knowledge of postpartum physiology and the myriad forms of mental illness that may emerge in this vulnerable time, in order to quickly make a diagnosis and formulate a treatment plan. This review aims to characterize the most common reasons for postpartum consultation, review postpartum physiology and psychiatric conditions, and propose an evidence-based, practical approach to treatment. A literature search using the terms "postpartum," "obstetric," "consultation," and "psychiatry" yielded six studies that identified reasons for psychiatric consultation to the obstetrics and gynecology services. These studies informed the structure of the article such that we review the most common reasons for consultation and how to approach each issue. The most common reason for consultation is past psychiatric history, often in the absence of current symptoms. For each clinical situation, including depression, adverse birth events, and psychosis, we present a differential diagnosis, as well as risk factors, clinical signs, and recommended treatment.

High prevalence of post-partum depression in women with coeliac disease

AIM: To explore the prevalence of post-partum depression (PPD) in coeliac disease (CD).

METHODS: We performed a case-control study evaluating the prevalence of PPD in CD patients on gluten-free diet (GFD) compared to that of healthy subjects experiencing a recent delivery. All participants were interviewed about menstrual features, modality and outcome of delivery and were evaluated for PPD by Edinburgh Postnatal Depression Scale (EPDS).

RESULTS: The study included 70 CD patients on GFD (group A) and 70 controls (group B). PPD was present in 47.1% of CD women and in 14.3% of controls (P < 0.01; OR = 3.3). Mean EPDS score was higher in CD compared to the controls (mean score: group A 9.9 ± 5.9; group B 6.7 ± 3.7; P < 0.01). A significant association was observed between PPD and menstrual disorders in CD (69.7% vs 18.9%; P < 0.001; OR = 3.6).

CONCLUSION: PPD is frequent in CD women on GFD, particularly in those with previous menstrual disorders. We suggest screening for PPD in CD for early detection and treatment of this condition.

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.

Nutritional factors associated with antenatal depressive symptoms in the early stage of pregnancy among urban South Indian women

Many women of reproductive age from developing countries have poor nutritional status, and the prevalence of depression during pregnancy is high. The objective of the present study was to assess the prevalence of antenatal depressive symptoms in early pregnancy, and to identify the demographic and nutritional factors associated with these symptoms in a sample of urban South Indian pregnant women. This cross-sectional study was the baseline assessment of a prospective randomized controlled trial of vitamin B12 supplementation in urban pregnant south Indian women between the ages of 18 and 40 years ( www.clinicaltrials.gov : NCT00641862). 365 women in their first trimester of pregnancy were screened for depressive symptoms at an urban clinic in Karnataka, South India, using the Kessler Psychological Distress Scale (K-10). Nutritional, clinical and biochemical factors were also assessed. Mean (SD) age of the cohort was 22.6 (3.7) years and mean (SD) BMI was 20.4 (3.3) kg/m(2). 121 (33 %) of the women in the 1st trimester had symptoms consistent with depression (K-10 score >6). In multivariate log binomial regression analysis, presence of antenatal depressive symptoms in the first trimester were positively associated with vomiting, prevalence ratio (PR) = 1.54 (95 % CI 1.10, 2.16) and negatively with anemia, PR = 0.67 (95 % CI 0.47, 0.96). Nutrient intakes, serum vitamin B12, methylmalonic acid, homocysteine and red cell folate levels were not associated with measures of depression. Antenatal depressive symptoms in early pregnancy are highly prevalent in urban Indian women and are more common in women with vomiting and without anemia. In this cross-sectional data, blood concentrations of vitamin B12 and folate were not associated with depressive symptoms. The relationship between nutritional status and depressive symptoms may require larger and longitudinal studies.

Estrogenic mediation of serotonergic and neurotrophic systems: implications for female mood disorders

Clinical research has demonstrated a significant sex difference in the occurrence of depressive disorders. Beginning at pubertal onset, women report a higher incidence of depression than men. Women are also vulnerable to the development of depressive disorders such as premenstrual dysphoric disorder, postpartum depression, and perimenopausal depression. These disorders are associated with reproductive stages involving changes in gonadal hormone levels. Specifically, female depression and female affective behaviors are influenced by estradiol levels. This review argues two major mechanisms by which estrogens influence depression and depressive-like behavior: through interactions with neurotrophic factors and through an influence on the serotonergic system. In particular, estradiol increases brain derived neurotrophic factor (BDNF) levels within the brain, and alters serotonergic expression in a receptor subtype-specific manner. We will take a regional approach, examining these effects of estrogens in the major brain areas implicated in depression. Finally, we will discuss the gaps in our current knowledge of the effects of estrogens on female depression, and the potential utility for estrogen receptor modulators in treatment for this disorder.

Depression in peri- and postmenopausal women: prevalence, pathophysiology and pharmacological management

Epidemiologic and clinic data have unequivocally supported the notion that women experience more psychiatric problems at some point in their lives compared with men, particularly mood and anxiety symptoms and sleep problems. It is also known that, for some women, such increased risk might be associated with reproductive cycle events such as the postpartum period or the menopausal transition. These periods are not only marked by substantial hormone variations but also quite often accompanied by stressful events and changes in personal, family and professional responsibilities. The complexity of these reproductive-related 'windows of vulnerability' poses a challenge to physicians and other professionals dedicated to women's health across the lifespan. The menopausal transition and early postmenopausal years constitute a characteristic example; during this period in life, dynamic changes in sex hormones and reproductive function co-occur with modifications in metabolism, sexuality, lifestyle behaviours and overall health, sometimes affecting a woman's quality of life and overall functioning. For most women, however, this transition has little or no significant impact on their mental wellness. A prior depressive episode--particularly if related to reproductive events--is the strongest predictor of mood symptoms or depression during menopausal years. Also, the presence and severity of vasomotor symptoms and other health-related issues appear to modulate the risk for depression in midlife women. Mechanistically, estrogen plays an important modulatory role in mood and cognitive regulation, hence the effects noted when midlife women are exposed to significant estrogen fluctuations or to estrogen-based therapies (use or withdrawal). Transdermal estradiol, as well as serotonergic and noradrenergic antidepressants, have shown efficacy in the management of depression in this population. Other evidence-based treatment options (hormonal, pharmacological, behavioural) are available to clinicians and health professionals who care for this population.

Early predictive biomarkers for postpartum depression point to a role for estrogen receptor signaling

BACKGROUND

Postpartum depression (PPD) affects approximately 13% of women and has a negative impact on mother and infant, hence reliable biological tests for early detection of PPD are essential. We aimed to identify robust predictive biomarkers for PPD using peripheral blood gene expression profiles in a hypothesis-free genome-wide study in a high-risk, longitudinal cohort.

METHOD

We performed a genome-wide association study in a longitudinal discovery cohort comprising 62 women with psychopathology. Gene expression and hormones were measured in the first and third pregnancy trimesters and early postpartum (201 samples). The replication cohort comprised 24 women with third pregnancy trimester gene expression measures. Gene expression was measured on Illumina-Human HT12 v4 microarrays. Plasma estradiol and estriol were measured. Statistical analysis was performed in R.

RESULTS

We identified 116 transcripts differentially expressed between the PPD and euthymic women during the third trimester that allowed prediction of PPD with an accuracy of 88% in both discovery and replication cohorts. Within these transcripts, significant enrichment of transcripts implicated that estrogen signaling was observed and such enrichment was also evident when analysing published gene expression data predicting PPD from a non-risk cohort. While plasma estrogen levels were not different across groups, women with PPD displayed an increased sensitivity to estrogen signaling, confirming the previously proposed hypothesis of increased sex-steroid sensitivity as a susceptibility factor for PPD.

CONCLUSIONS

These results suggest that PPD can be robustly predicted in currently euthymic women as early as the third trimester and these findings have implications for predictive testing of high-risk women and prevention and treatment for PPD.