Controlled prospective study of postpartum mood disorders: comparison of childbearing and nonchildbearing women

Perinatal depression screening using smartphone technology: Exploring uptake, engagement and future directions for the MGH Perinatal Depression Scale (MGHPDS)

Women may experience new-onset or worsening depressive disorders during pregnancy and the postpartum. If untreated, there may be detrimental consequences to the health and wellbeing of the woman and to her baby. There is a need for improved tools and approaches that can be easily and broadly implemented to effectively detect depression during the perinatal period. Early identification of depression during pregnancy is an important first step towards connecting women to treatment and preventing continued depression into the postpartum or beyond. This report provides preliminary findings from a pilot study of a digital screening app for perinatal depression expiring potential for app reach, engagement, and user demographics and mental health symptoms. With mainly passive recruitment efforts, we collected cross-sectional mental health data on over 700 women during the perinatal period, including women across over 30 countries. We report on mean depression scores among women during pregnancy and the postpartum as well as on constructs that are commonly comorbid with depression, including anxiety, sleep dysregulation, and perceived stress. Over half of the women during pregnancy and over 70% of women in the postpartum had a depression score indicative of clinical depression. Future research directions for this work and potential for public health impact are discussed, including longitudinal data collection and analyses of symptomology over time and embedding evidence-based digital therapeutics into the app as a means to increase access to mental health services.

Effect of Excessive Body Weight and Emotional Disorders on the Course of Pregnancy and Well-Being of a Newborn before and during COVID-19 Pandemic

This study aimed to evaluate whether excessive body weight and the COVID-19 pandemic affect depression, and subsequently whether depression, excessive body weight, and the COVID-19 pandemic affect the course of pregnancy, as well as the well-being of a newborn. The research material included data retrieved from the medical records of 280 pregnant women who were provided with care by medical facilities in Lublin (100 women with normal weight, 100 overweight women, 50 with Class I and 30 with Class II obesity). They completed a Beck depression inventory (BDI) in pregnancy twice, in order to assess the risk of occurrence of postpartum depression. Pre-pregnancy BMI positively correlated with the severity of depression, both at 10–13 weeks of pregnancy (p < 0.001), and at 32 weeks of pregnancy (p < 0.001). The higher the pre-pregnancy BMI, on average the higher the severity of depression. The severity of depression was significantly higher during the pandemic than before it in women with normal body weight before pregnancy (p < 0.001), as well as in those overweight (p < 0.001) and with Class II obesity (p = 0.015). Excessive body weight before pregnancy leads to depressive disorders during pregnancy, increases the risk of preterm delivery, and exerts a negative effect on the state of a newborn. Depressive symptoms among pregnant, overweight and obese women intensified during the COVID-19 pandemic.

Effects of COVID-19 Epidemic Lockdown on Postpartum Depressive Symptoms in a Sample of Italian Mothers

The extraordinary health emergency of the COVID-19 pandemic represents a new challenge for mental health researchers and clinical practitioners. The related containment measures may be a risk factor for psychological distress and mood disorders, especially in at-risk populations. This study aims to explore the impact of COVID-19 on postpartum depressive symptoms in mothers with children below 1 year of age. An online questionnaire survey was therefore conducted in Italy between May and June 2020. The survey consisted of several self-administered questionnaires: besides some ad-hoc questionnaires, the Edinburgh Postnatal Depression Scale (EPDS), the Scale of Perceived Social Support (SPSS) and the Maternity Social Support Scale (MSSS) were used. Two hundred forty-three Italian women were included in the study. The prevalence of postpartum depression symptomatology among mothers was 44%, as measured through the EPDS (cut-off >12). Women who spent the isolation in northern Italy adopted maladaptive coping strategies significantly more than women living in areas at lower risk. The analysis highlighted a significant difference between the group that was not directly affected by the virus and women who have had a direct or indirect contact with it. Besides situational factors specific to the pandemic, the results show that there are some risk factors tied to the personal history of the mother (e.g., having had a previous abortion). These data should inform and enlighten future protocols of intervention.

Frank Beach Award Winner - The future of mental health research: Examining the interactions of the immune, endocrine and nervous systems between mother and infant and how they affect mental health

Pregnancy and the postpartum period are periods of significant change in the immune and endocrine systems. This period of life is also associated with an increased risk of mental health disorders in the mother, and an increased risk of developmental and neuropsychiatric disorders in her infant. The collective data described here supports the idea that peripartum mood disorders in mother and developmental disorders in her infant likely reflects multiple pathogeneses, stemming from various interactions between the immune, endocrine and nervous systems, thereby resulting in various symptom constellations. In this case, testing the mechanisms underlying specific symptoms of these disorders (e.g. deficits in specific types of learning or anhedonia) may provide a better understanding of the various physiological interactions and multiple etiologies that most likely underlie the risk of mental health disorders during this unique time in life. The goal here is to summarize the current understanding of how immune and endocrine factors contribute to maternal mental health, while simultaneously understanding the impact these unique interactions have on the developing brain of her infant.

Maternal programming: Application of a developmental psychopathology perspective

The fetal phase of life has long been recognized as a sensitive period of development. Here we posit that pregnancy represents a simultaneous sensitive period for the adult female with broad and persisting consequences for her health and development, including risk for psychopathology. In this review, we examine the transition to motherhood through the lens of developmental psychopathology. Specifically, we summarize the typical and atypical changes in brain and behavior that characterize the perinatal period. We highlight how the exceptional neuroplasticity exhibited by women during this life phase may account for increased vulnerability for psychopathology. Further, we discuss several modes of signaling that are available to the fetus to affect maternal phenotypes (hormones, motor activity, and gene transfer) and also illustrate how evolutionary perspectives can help explain how and why fetal functions may contribute to maternal psychopathology. The developmental psychopathology perspective has spurred advances in understanding risk and resilience for mental health in many domains. As such, it is surprising that this major epoch in the female life span has yet to benefit fully from similar applications.

The impact of maternal anxiety disorder on mother-infant interaction in the postpartum period

Background

This study investigated whether postpartum anxiety disorder is associated to altered patterns of infant as well as maternal engagement in a Face-to-Face-Still-Face interaction (FFSF).

Sampling and methods

n = 39 women with postpartum DSM-IV anxiety disorder and n = 48 healthy mothers were videotaped during a FFSF with their infant (M = 4.1 months).

Results

Infants of the clinical group showed significantly less positive engagement during the play episode than infants of controls. This result depended on infant sex: male controls demonstrated more positive interaction than males of anxious mothers. There was no such effect for female infants who engaged significantly less positively during the play episode than males and did not change their positive engagement during the FFSF. These findings imply pronounced interactive positivity and early vulnerability to maternal anxiety symptoms in male infants. Only the infants of the controls showed the still-face effect. They also protested significantly more during the still-face, while the clinical infants’ protest increased significantly during the reunion. Women of both groups did not differ in their interaction. Maternal intrusiveness was associated to infant protest in the course of the FFSF.

Conclusions

Results suggest that mother-infant intervention should consider affect regulation and infant sex-specific characteristics in anxious mother-infant dyads.

Frequency, trends, and antecedents of severe maternal depression after three million U.S. births

Background

Postpartum depression carries adverse consequences for mothers and children, so widespread screening during primary care visits is recommended. However, the rates, timing, and factors associated with significant depressive episodes are incompletely understood.

Methods and findings

We examined the Healthcare Cost and Utilization Project (HCUP) State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases from California (2005–2011) and Florida (2005–2012). Within 203 million records, we identified 3,213,111 births and all mothers who had hospital encounters for severe depression within 40 weeks following delivery. We identified 15,806 episodes of postpartum depression after 11,103 deliveries among 10,883 unique women, and calculated an overall rate of 36.7 depression- associated hospital visits per 10,000 deliveries. Upward trends were observed in both states, with combined five-year increases of 34%. First depressive events were most common within 30 days of delivery, but continued for the entire observation period. About half (1,661/3,325) of PPD first episodes occurred within 34 days of delivery, 70% (2,329/3,325) by the end of the second month, and 87% (2,893/3,325) before four-months of the delivery. Women with private insurance were less likely to have hospital encounters for depression than women with public insurance and women with depression were much more likely to have had some kind of hospital encounter at some time during their pregnancies. Rates of depression increased with the number of prenatal hospital encounters in a “dose-dependent” fashion: the rate of depression was 17.2/10,000 for women with no prenatal hospital visits, doubling for women with at least one encounter (34.9/10,000), and increasing 7-fold to 126/10,000 for women with three or more encounters during their pregnancies.

Conclusions

Our findings suggest that (1) hospital encounters for post-partum depression are increasing, (2) screening should begin very early and continue for the first year after delivery, and (3) added attention should be given to women who had hospital encounters during their pregnancies.

Homeopathic Treatment for Postpartum Depression: A Case Report

Postpartum psychosis has long-lasting consequences for mother and child. Beside depression, sleep and eating disturbances, exhaustion, social withdrawal, and anxiety, postpartum depression can also interfere with normal maternal-infant bonding and adversely affect child development. Recent reports show that most affected pregnant women are hesitant about taking antidepressant drugs, with a high percentage discontinuing their use. Some authors suggest that the reluctance of pregnant women to take antidepressant drugs should encourage clinicians to discuss with their patients the use of psychological interventions or alternative forms of treatment. In this article, a case of severe postpartum depression, treated successfully with homeopathic therapy, is presented. Considering the high noncompliance of women suffering from postpartum depression with conventional antidepressant medication, research in safe complementary medical methods is justified. One of these methods should be homeopathy.

The Relationship Among Breastfeeding, Postpartum Depression, and Postpartum Weight in Mexican American Women

OBJECTIVE

To determine if symptoms of postpartum depression and postpartum weight varied according to the level of breastfeeding among women of Mexican origin at 1 month and 6 months postpartum.

DESIGN

Secondary quantitative analysis to study the differences in postpartum weight and depression among the mothers in the study who breastfed and those who did not.

SETTING

A heavily Hispanic community located in a major Southwestern U.S. city.

PARTICIPANTS

Women of Mexican origin (N = 150) who enrolled during their third trimesters in a local Special Supplemental Nutrition Program for Women, Infants, and Children clinic and were followed for 6 months.

METHODS

Weight was measured at 1 month and at 6 months postpartum at home visits with validated digital scales. Breastfeeding was measured according to World Health Organization criteria and recorded after monthly phone calls. Depression was measured at home visits at 1 month and 6 months with the Edinburgh Postnatal Depression Scale.

RESULTS

At 6 months postpartum, participants who did not breastfeed had the highest scores on the Edinburgh Postnatal Depression Scale; participants who breastfed nonexclusively had the lowest scores (p = .067). At both time points, there was a significant difference in weight (p = .017) between women who were doing any breastfeeding and women who were not breastfeeding.

CONCLUSION

Breastfeeding, even if not exclusive, contributed to lower depression scores and significantly lower postpartum weight among this sample of Mexican American women.

The mutual influences between depressed Macaca fascicularis mothers and their infants

Objective

To assess the influence of infant rearing on the behavior of depressed adult female Macaca fascicularis and the influence of depressed infant-rearing adult female Macaca fascicularis on their infants in a free enclosure environment.

Methods

Here, 20 depressed subjects and then 20 healthy subjects were randomly selected from a total population of 1007 adult female Macaca fascicularis subjects. Four depressed subjects and eight healthy subjects were rearing infants. By focal observation, three trained observers video-recorded the selected subjects over a total observational period of 560 hours. The video footage was analyzed by qualified blinded analysts that coded the raw footage into quantitative behavioral data (i.e., durations of 53 pre-defined behavioral items across 12 behavioral categories) for statistical analysis.

Results

Between infant-rearing and non-rearing healthy subjects, ten differential behaviors distributed across five behavioral categories were identified. Between infant-rearing and non-rearing depressed subjects, nine behaviors distributed across five behavioral categories were identified. Between infant-rearing healthy and infant-rearing depressed subjects, fifteen behaviors distributed across six behavioral categories were identified.

Conclusion

Infant-rearing depressed adult female Macaca fascicularis subjects may have a worse psychological status as compared to non-rearing depressed counterparts. Infant rearing may negatively influence depressed Macaca fascicularis mothers. Infant-rearing depressed subjects were less adequate at raising infants as compared to infant-rearing healthy subjects. Thus, maternal depression in this macaque species may negatively impact infatile development, which is consistent with previous findings in humans.

Physical activity during pregnancy and postpartum depressive symptoms

OBJECTIVE

to examine the associations between total and domain-specific moderate-to-vigorous physical activity (MVPA) during pregnancy and postpartum depressive symptoms.

DESIGN

a prospective cohort study.

PARTICIPANTS

data were obtained from 652 women recruited from prenatal clinics at University of North Carolina Hospitals during 2001-2005 for the Pregnancy, Infection, and Nutrition (PIN) Postpartum Study.

MEASUREMENTS

MVPA measured at 17-22 and 27-30 weeks' gestation was investigated as a predictor of depressive symptoms assessed with the Edinburgh Postnatal Depression Scale at 3 months postpartum.

FINDINGS

total MVPA was not associated with depressive symptoms when using either 17-22 weeks' gestation or 27-30 weeks' gestation MVPA measures. In general, there were minimal associations for domain-specific MVPA. The direction of associations between depressive symptoms and work, adult and child care, and outdoor household MVPAs differed by time of measurement.

KEY CONCLUSIONS

the association between physical activity and postpartum depressive symptoms may differ with the timing of assessment. Additional studies (i.e. with a larger sample of women or a sample of at-risk women) following women throughout pregnancy and postpartum are needed to explore differences in the influence of physical activity on depressive symptoms.

IMPLICATIONS FOR PRACTICE

assessment of potential risk factors for elevated depressive symptoms, such as participation levels in different types of physical activity, throughout pregnancy may assist in determining who may be susceptible to postpartum depression.

Use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy and disorganized infant-mother attachment

OBJECTIVE

Examine the quality of infant-mother attachment in a prospective case series of infants whose mothers took selective serotonin reuptake inhibitors (SSRIs) during pregnancy.

BACKGROUND

SSRIs are prescribed to 2 to 6% of pregnant women (National Collaborating Centre for Mental Health, 2007; Stewart, 2011). Recent articles on the use of SSRIs during pregnancy note the increased risk for problematic infant-mother relationships among mothers with untreated postpartum depression (Gentile, 2011; Stewart, 2011). However, little is known about the quality of infant-mother relationships among mothers who took SSRIs during pregnancy.

METHODS

Five mothers who took SSRIs during pregnancy were recruited from a community study of infant development. Mothers completed ratings of postpartum depression symptoms (Beck Depression Inventory) 4 to 6 times between 1 month and 1 year following the infant's birth. At 1 year postpartum, quality of infant-mother attachment was assessed using the strange situation procedure.

RESULTS

Four of the 5 infant-mother dyads (80%) were classified as disorganized, a rate considerably higher than in postpartum depression samples.

CONCLUSION

These results are used to raise questions about the clinical implications of research on in utero exposure to SSRIs, perinatal depression, and disorganized attachment. Specifically, this case series raises questions about using research on the link between postpartum depression and infant-mother attachment as a rationale for the use of SSRIs during pregnancy. Current research indicates use of SSRIs during pregnancy may: 1) increase risk for disorganized attachment, 2) decrease risk for disorganized attachment, or 3) have no effect on disorganized attachment.

Prospective study on the association between harm avoidance and postpartum depressive state in a maternal cohort of Japanese women

Background

Recent studies have displayed increased interest in examining the relationship between personality traits and the onset, treatment response patterns, and relapse of depression. This study aimed to examine whether or not harm avoidance (HA) was a risk factor for postpartum depression measured by the Edinburgh Postnatal Depression Scale (EPDS) and the state dependency of HA.

Methods

Pregnant women (n=460; mean age 31.9±4.2 years) who participated in a prenatal program completed the EPDS as a measure of depressive state and the Temperament and Character Inventory (TCI) as a measure of HA during three periods: early pregnancy (T1), late pregnancy (around 36 weeks), and 1 month postpartum (T2). Changes in EPDS and HA scores from T1 to T2 were compared between the non depressive (ND) group and the postpartum depressive (PD) group.

Results

There was no significant difference in the level of HA between the ND and PD groups at T1. In the ND group, EPDS and HA scores did not change significantly from T1 to T2. In the PD group, both scores increased significantly from T1 to T2 (EPDS, p<0.0001; HA, p<0.048). In the ND and PD groups, a significant positive correlation was observed in changes in EPDS and HA scores from T1 to T2 (r=0.31, p=0.002).

Conclusions

These results suggest that HA cannot be considered a risk factor for the development of postpartum depression measured by EPDS. Furthermore, HA may be state dependent.

Once a mother, always a mother: maternal experience protects females from the negative effects of stress on learning

Women experience profound hormonal fluctuations throughout their reproductive lives. They are especially susceptible to disturbances in mood and cognition during the transition from pregnancy into postpartum and motherhood (Brummelte & Galea, 2010). Their behavioral and hormonal responses to stressful stimuli are also altered during this time. These changes are not limited to humans but occur in many mammalian species. Virgin female rats express a severe learning deficit in associative eyeblink conditioning after a stressful life event (Wood, Beylin, & Shors, 2001; Wood & Shors, 1998), but lactating females or those that are caring for young learn well even after the stressor (Leuner & Shors, 2006). However, we do not know whether maternal experience persistently alters learning after a stressful event. Here we hypothesized that females that had been maternal at some time in their lives would learn well even after exposure to a stressful event. To test this hypothesis, females that had at least one brood of young and expressed a normal estrous cycle were exposed to an acute stressful event that reliably impairs learning in virgin females. Animals were trained 24 hr later with classical eyeblink conditioning. Exposure to the stressor suppressed learning in virgins but not in females that had been mothers at some time in their lives. These data suggest that maternal experience induces a protective mechanism in mothers, which promotes associative learning long after the offspring have left their care.

Associations between physical activity and postpartum depressive symptoms

BACKGROUND

Postpartum women are at increased risk for developing depression, which can contribute to the ill health of the mother and her family. Previous research indicates that mothers who are physically active during leisure experience lower levels of postpartum depressive symptoms than do inactive mothers. The objective of this investigation was to examine the associations between total and domain-specific moderate to vigorous physical activity (MVPA) and depressive symptoms postpartum.

METHODS

Data were obtained from 550 women who participated in the Pregnancy, Infection, and Nutrition (PIN) Postpartum Study, a prospective cohort of mothers who delivered liveborn infants from October 2002 to December 2005 in North Carolina. Three-month postpartum MVPA was investigated as a predictor of 12-month postpartum depressive symptoms.

RESULTS

Those who participated in MVPA had two times the odds of developing elevated depressive symptoms at 12 months postpartum than those with no MVPA (odds ratio [OR] 2.00, 95% confidence interval [CI] 0.71-6.75). Different associations were suggested when examining domain-specific MVPA. Those participating in adult and child care and indoor household MVPA at 3 months postpartum had more than double the odds of developing elevated depressive symptoms at 12 months postpartum (OR 2.66, 95% CI 1.03, 8.11 and OR 2.72, 95% CI 0.96-10.18, respectively). Work MVPA conferred a doubling of the odds (OR 1.95, 95% CI 0.46-7.13), but recreational and outdoor household MVPA showed no associations with depressive symptoms.

CONCLUSIONS

Associations between MVPA and depressive symptoms differed by domain among postpartum women. Future studies of postpartum depressive symptoms should explore reasons for differences in physical activity by domain.

Occurrence and correlates of postpartum depression in overweight and obese women: results from the active mothers postpartum (AMP) study

OBJECTIVE

Postpartum depression (PPD) is a significant concern for new mothers and their infants, as well as the health professionals who care for them. Obesity may be a risk factor for depression, and therefore, for PPD specifically. We examined the occurrence and risk factors for PPD in a sample of overweight and obese new mothers.

METHODS

In this cross-sectional study, 491 women who were overweight or obese prior to pregnancy completed the Edinburgh Postnatal Depression Scale (EPDS) 6 weeks postpartum, along with a number of other health- and pregnancy-related measures. Occurrence of depression was investigated, as well as bivariate and multivariate relationships between depression and demographic and health-related characteristics.

RESULTS

As determined by an EPDS score of 13 or higher, the prevalence of PPD was 9.2%. Three items on the scale stood out as drivers of the total score ("blame myself unnecessarily", "anxious or worried," "feel overwhelmed"). Bivariate correlates of depression included education, income, marital status, and self-reported chronic illness; income remained significant in the multivariate logistic regression model. BMI was not related to postpartum depression.

DISCUSSION

In this group of overweight and obese women, there was no association between BMI group and postpartum depression.

EFFECTS OF MATERNAL DEPRESSION AND PANIC DISORDER ON MOTHER-INFANT INTERACTIVE BEHAVIOR IN THE FACE-TO-FACE STILL-FACE PARADIGM

The present study evaluated the interactive behavior of three groups of mothers and their 3-month-old infants in the Face-to-Face Still-Face paradigm. The mothers had either a clinical diagnosis of major depressive disorder (MDD, n = 33) with no comorbidity, a clinical diagnosis of panic disorder (PD, n = 13) with no comorbidity, or no clinical diagnosis (n = 48). The sample was selected to be at otherwise low social and medical risk, and all mothers with PD or MDD were in treatment. The findings indicated that (a) infants of mothers with PD or MDD displayed the traditional still-face and reunion effects described in previous research with nonclinical samples; (b) the 3-month-old infants in this study showed similar, but not identical, gender effects to those described for older infants; and (c) there were no patterns of maternal or infant interactive behavior that were unique to the PD, MDD, or control groups. These results are discussed in light of mothers' risk status, receipt of treatment, severity of illness, and comorbidity of PD and MDD.

Depression during pregnancy: the potential impact of increased risk for fetal aneuploidy on maternal mood

Depression during pregnancy can have serious consequences for families. Indications of fetal aneuploidy can induce maternal stress, a risk factor for depression. Few studies have assessed symptoms of depression in pregnant women soon after they receive results indicating increased risk for fetal aneuploidy. We compared symptoms of depression in women who had increased risks for fetal aneuploidy with two other groups of pregnant women at similar gestational ages: controls, and women taking antidepressant medications (MEDS). Eighty-one women attending the British Columbia (BC) Medical Genetics (MG) Program regarding positive maternal serum screens or ultrasound soft marker findings completed the Edinburgh Postnatal Depression Scale (EPDS). Control (n = 41) and MEDS (n = 41) groups were recruited from the community or the BC Reproductive Mental Health program. A threshold score of 12 on the EPDS was used to calculate percentages of women likely to be depressed. Mean EPDS scores were compared using anova, followed by post-hoc tests. In the control, MG, and MEDS groups, 2.4%, 35%, and 52.4% of women, respectively, scored above 12. Mean EPDS score was significantly higher in the MG group than in the control group (p < 0.0001). These results suggest a place for depression screening in prenatal genetic counseling.

Postpartum depression: racial differences and ethnic disparities in a tri-racial and bi-ethnic population

OBJECTIVES

This research investigated the differences and disparities of postpartum depression in a sample of African American, Hispanic, Native American, and White women.

METHODS

A sample of 586 women were administered the Beck-Gable PDSS at 6-weeks postpartum. Factor analysis was applied to analyze the similarities among African American, Hispanic, Native American, and White participants. Confidence intervals of the rates of depression by group were estimated, followed by statistical tests to determine the differences among these rates. Risk assessment was performed with factor analysis and correlation methods.

RESULTS

Hispanic women had a remarkably lower depression rate (2.5%) than other groups (P-values<0.05). Significant differences for major depression were not found among African American, Native American, and White women; but Whites had higher minor depression (P-values<0.05). Native American women had the highest rate of major depression (18.7%) and an average minor depression (10.5%). Although Whites had the second highest major depression (17.6%) and the highest minor depression (19.6%), their average full score (76.1) was noticeably lower than that of Native Americans (82.9) and slightly lower than that of African Americans (78.9; major and minor depression rates: 14.8% and 9.9%). The sample also demonstrated strong associations of depression with depression history and breastfeeding.

CONCLUSION

Statistically, postpartum depression can be ranked from high to low as Native Americans, Whites, African Americans and Hispanics (Hispanics have remarkably lower depression rates). This information is critically important to clinicians, researchers, agency administrators and social workers who work with these populations.

Transfer of escitalopram and its metabolite demethylescitalopram into breastmilk

AIMS

To investigate the transfer of escitalopram and its demethyl metabolite into milk, the absolute and relative infant doses via milk and to assess any unwanted effects in the breastfed infant.

METHODS

Multiple samples of blood and milk were obtained over a dose interval at steady state from eight women who were taking escitalopram for postnatal depression. Drug concentrations in plasma and milk were measured by high-performance liquid chromatography and milk/plasma ratio (M/P(AUC)), absolute infant dose and relative infant dose were estimated by standard methods. Their breastfed infants were also examined clinically and in five infants a blood sample was taken for drug analysis.

RESULTS

The median dose taken by the women was 10 mg day(-1). The mean (95% confidence interval) M/P(AUC) was 2.2 (2.0, 2.4) for escitalopram and 2.2 (1.9, 2.5) for demethylescitalopram. Absolute infant doses were 7.6 microg kg(-1) day(-1) (5.2, 10.0) for escitalopram and 3.0 microg kg(-1) day(-1) (2.4, 3.6) for demethylescitalopram. The total relative infant dose for escitalopram plus its demethyl metabolite was 5.3% (4.2, 6.4) as escitalopram equivalents. All of the infants had met normal developmental milestones and no adverse effects were seen. Compared with average maternal plasma concentrations (24 microg l(-1)), the concentrations of the parent drug and its metabolite in plasma from five infants were most commonly below the limit of detection (</=3 microg l(-1)).

CONCLUSION

The study shows that escitalopram is safe for use during breastfeeding. Because its absolute infant dose is lower than that for an equivalent antidepressant dose of rac-citalopram, it may be preferred over rac-citalopram in treating depression in lactating women. Nevertheless, each decision to breastfeed should always be made on the basis of an individual risk:benefit analysis.

Antidepressant prevention of postnatal depression

A systematic review sought to discover whether antidepressant drugs are effective in preventing postnatal depression. Only two small trials were found and it was not possible to draw firm conclusions.

Transfer of the antidepressant mirtazapine into breast milk

AIMS

To investigate the transfer of mirtazapine and desmethylmirtazapine into milk and to calculate dose to the infant via milk.

METHODS

Plasma and milk samples were obtained from eight breast-feeding women who were taking a median dose of 38 mg mirtazapine per day. Milk/plasma ratio (M/P) and infant doses were estimated by standard methods. The infants were examined clinically and in four infants blood was taken for analysis.

RESULTS

Mean (95% confidence interval) relative infant doses for mirtazapine and desmethylmirtazapine (n = 8) were 1.5% (0.8, 2.2) and 0.4% (0.2, 0.6) respectively. The mean M/P (area under curve n = 4, single or paired samples n = 3) was 1.1 (0.7,1.5) for mirtazapine and 0.6 (0.5, 0.7) for desmethylmirtazapine. No adverse effects were seen. Mirtazapine was detected (1.5 microg l(-1)) in only one of four infants tested.

CONCLUSION

We suggest that mirtazapine use by lactating women is safe for the breast-fed infant. Nevertheless, each decision to breast feed should always be made on the basis of an individual risk/benefit analysis.

Transfer of reboxetine into breastmilk, its plasma concentrations and lack of adverse effects in the breastfed infant

OBJECTIVE

To investigate the transfer of reboxetine into milk, the absolute and relative infant doses via milk and to assess plasma concentrations and adverse unwanted effects in the breastfed infant.

METHODS

Multiple samples of blood and milk were obtained over a dose interval at steady-state from four women who were taking reboxetine for postnatal depression. Drug concentrations in plasma and milk were measured by high performance liquid chromatography and milk/plasma ratio (M/P), absolute infant dose and relative infant dose were estimated by standard methods. Their four, breastfed, infants were also examined clinically, and a blood sample was taken for drug analysis.

RESULTS

The median (range) dose taken by the women was 6 (4-10) mg/day. There was no significant difference in reboxetine concentration between paired fore-and hind-milk samples. The mean (95% CI) M/P was 0.06 (0.03, 0.09). Absolute infant dose was 1.7 (0.7, 2.4) microg/kg/day for reboxetine while the relative infant dose was 2.0% (1.3, 2.7%). Three of the infants met normal developmental milestones and no adverse effects were seen in any infant. The fourth infant had developmental problems that were not associated with the maternal reboxetine therapy. The concentrations of reboxetine in plasma from the four infants were <4 microg/l, 2.6 microg/l, 2.3 microg/l and 5 microg/l, respectively.

CONCLUSION

The study suggests that reboxetine use by lactating women is safe for the breastfed infant. Nevertheless, our study had only four mother/baby pairs, and each decision to breastfeed should always be made on the basis of an individual risk/benefit analysis.

Impact of infant health problems on postnatal depression: pilot study to evaluate a health visiting system

This pilot study aimed to elucidate whether or not mothers who receive neonatal home visits tend to suffer from depressive disorders during the first postpartum year and to examine what kinds of factors were related to the postnatal depression observed in these mothers. The subjects consisted of 70 Japanese mothers who received neonatal home visits and completed the 1-year study. At their first visit, the health visitors asked about their personal backgrounds and early postpartum mood, and depression was assessed by a Japanese translation of the Edinburgh Postnatal Depression Scale (EPDS). At 12 months postpartum, a diagnostic interview using the Structured Clinical Interview for DSM-IV (SCID) was performed to confirm the maternal diagnosis by a psychiatrist. An assessment of infant development using the Denver Developmental Screening Test (DDST) was administered to each infant by a psychologist. Nineteen mothers (27%) were categorized as having had a new onset of depression (12 major depressive disorders and seven depressive disorders not otherwise specified). In comparison to the non-depressed mothers, infant-related health problems that required either outpatient treatment or hospitalization were significantly related to postnatal depression. Pediatric diseases in infants did not always precede their mother's depression. The extra burden of caring for a sick infant tends to increase the risk of developing postpartum depression. As a result, neonatal home visits by health visitors may therefore be a potentially crucial opportunity to provide emotional support, particularly for mothers with the extra burden of having to care for sick infants.

Prenatal depression: a randomized controlled trial in the emotional health of primiparous women

The prevalence of postnatal depression (10%-15%) renders it a major public health problem not only for the depressed mother but also for the infant, who may suffer from behavioral disturbances and cognitive delays in later years. This study aimed at evaluating an educational intervention to alleviate postnatal depression and at generally measuring the prenatal and postnatal mood of primiparous women. A prospective, randomized controlled trial of an education intervention to reduce postnatal depression was conducted at three sites in Australia enrolling a total of 184 primiparous women. The intervention consisted of an information booklet on postnatal depression and an audiotape of one woman's journey through clinical postnatal depression. Mood was assessed once prenatally (12-28 weeks) and twice postnatally (8-12 weeks and 16-24 weeks) using the Scale for Assessment of Depression and Schizophrenia modified for pregnant and postnatal women (SADS-M). Demographic and social support data were also collected at enrollment. Comparisons between the control group and the intervention group revealed no differences; the educational intervention did not show any effect when women's mood was measured by the SADS-M. Overall, a general, significant, steady decrease of depressive tendencies was observed when the two postnatal assessments were compared to the prenatal measurements. Women were less depressed postnatally than prenatally. This overall improvement of mood was significant in most SADS-M items. The exceptions were discouragement, anxiety, anger, and irritability, which did not reach significance. Additional multivariate analyses revealed no relevant influence of social support or demographic variables on the changes in mood. The main results that the education intervention had no effect and women, overall, were more depressed prenatally than postnatally contributes further evidence to the view that the prenatal period is a separate entity from the postnatal period, with distinctive psychoneuro-endocrine pathways and, thus, suggesting different profiles of women's experience. This evidence indicates the necessity to screen, refer, and manage prenatal maternal mood as an entity in its own right, rather than as a window on the postnatal period.

The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women

The purpose of the research project was to examine the effects of exercise, social support and depression on postnatal women who reported experiencing postnatal depression. A 12-week randomized, controlled trial was conducted investigating the effects of an exercise intervention group (a pram-walking programme for mothers and their babies ) compared to a social support group (non-structured sessions, similar to a playgroup). Participants in both groups had given birth in the past 12 months. Pretest data of physical fitness and structured questionnaires were compared to post-test effects. The primary outcomes were to reduce the depressive symptomatology and improve fitness levels of participants in the pram-walking group. Secondary outcomes were to improve the social support levels of the participants in both groups and explore women's views about the programmes. It was hypothesized that the pram-walking group participants would improve their feelings of depression and fitness levels compared to the social support group, but that both groups would improve their perceived levels of social support. The results showed that mothers in the pram-walking intervention group improved their fitness levels and reduced their level of depressive symptomatology significantly more than the social support group. There were no significant changes to social support levels for both groups. Therefore, a direct association between improvement in fitness was related to improvement in depression for the pram-walking group. However, it is also suggested that other factors in combination with improvements in fitness influenced improvements in depression levels. It is recommended that pram-walking programmes for mothers with postnatal depression be implemented as pilot research into existing available services.

The First-Time Fathers Study: a prospective study of the mental health and wellbeing of men during the transition to parenthood

OBJECTIVE

In comparison to its female counterpart, the transition of men to parenthood has been relatively neglected in previous research. The present paper argues that men may have gender-specific risk factors for perinatal psychological distress and may manifest distress in ways different from women. The prime objective of this research was to document changes in psychological, relationship and lifestyle parameters in a cohort of first time fathers from pregnancy to the end of the first postnatal year. The present paper reports on these changes.

METHOD

Three hundred and twelve men were assessed at 23 weeks of pregnancy and followed up at 3, 6 and 12 months postnatally, using a battery of self-report questionnaires covering psychological symptom levels, lifestyle variables and relationship/sexual functioning. Two hundred and four men completed all four assessments.

RESULTS

The men exhibited highest symptom levels in pregnancy with general, through small, improvement at 3 months and little change thereafter. Lifestyle variables showed small changes over the first postnatal year. Sexual functioning appeared to deteriorate markedly from pre-pregnancy levels with only minimal recovery by the end of the first year. The results highlight that the majority of men anticipated return of sexual activity to pre-pregnancy levels; however, this failed to eventuate.

CONCLUSIONS

Pregnancy, rather than the postnatal period, would appear to be the most stressful period for men undergoing the transition to parenthood. The results suggest that the most important changes occur relatively early in pregnancy. Thereafter, lack of change (rather than change) is the most noteworthy feature. These men appeared to be ill-prepared for the impact of parenthood on their lives, especially in terms of the sexual relationship. Further research to determine the timing and trigger of stress in pregnancy is recommended.

Antenatal depression and maternal-fetal attachment

BACKGROUND

In recent years, attention has been turned to maternal mental health in relation to the mother-child relationship accompanying a widening in focus, i.e. taking into account not only the puerperium, but also the stage of pregnancy. This applies to studies that have revealed a connection between depression and maternal attachment in the postpartum period and late pregnancy. This study, however, was designed to evaluate the maternal-fetal relationship in the first and second trimesters, being the first one to address this issue in these early stages.

SAMPLING AND METHODS

Zung's Self-Rating Depression Scale (ZSDS), the original Antenatal Maternal Attachment Scale (AMAS), and a questionnaire addressing peripheral factors were given to 216 pregnant women (3-6 months of gestation) who visited the Nagoya University Hospital between September 1998 and June 2001.

RESULTS

Contrary to reports on the latter stages of pregnancy, no direct association was observed between depression in mothers and maternal-fetal attachment before fetal movement was perceived.

CONCLUSION

However, education, form of employment, planning of pregnancy, and premenstrual mood changes were found to be associated with the ZSDS score (mean: 41.9), while form of employment, feelings regarding pregnancy, and sources of support were extracted as factors associated with the AMAS, which are of interest in terms of the subsequent association between depression and maternal-fetal attachment in the peri- and postnatal periods.

An Update on Mood and Anxiety Disorders During Pregnancy and the Postpartum Period

Because women in the childbearing years are vulnerable to mood and anxiety disorders, physicians in all patient care specialties need to be familiar with the prevalence and course of these disorders, particularly during pregnancy and the postpartum period. Systematic prospective data are limited on the onset of mood and anxiety disorders during pregnancy and the postpartum period as well as on the risk of relapse during these time periods in women with prior histories of the disorders. The literature on mood and anxiety disorders during pregnancy is frequently complicated by the use of various methodologies, procedures, and study populations, and inconsistencies in the postpartum time frame (up to 6 months after delivery) make the literature on epidemiology of postpartum disorders difficult to interpret. This article is an update of available information about the prevalence and course of mood and anxiety disorders in women during pregnancy and the postpartum period.

Parapartum mental illness: a long-term follow-Up study

All mothers (n = 79) in the county of Stockholm who gave birth to a child during 1976-77 and were also hospitalised for the first time in a psychiatric clinic were followed up after a mean interval of 15 years. The sample was classified according to the Research Diagnostic Criteria. Comparisons were made with matched obstetric controls. Five patients had died. The recurrence rate was 51% and 7. 3% relapsed after a subsequent childbirth. No difference was found between psychotic and non-psychotic mothers regarding mean sick-leave days per year. The majority of the women with a depressive disorder at index admission suffered from a minor depressive disorder. The women in the group with an unspecified functional psychosis showed a less severe course of illness than the women in the schizophrenia group.