Postpartum thyroid dysfunction and postpartum depression: are they two linked disorders?

Peripartum depression and its predictors: A longitudinal observational hospital-based study

BACKGROUND

Depression is a common problem in women in childbearing years due to burdens of motherhood and building a family. Few studies estimate the prevalence of antepartum depression compared to those in the postpartum period.

AIM

To estimate the prevalence and the severities of peripartum depression and major depressive disorder and their predictors.

METHODS

This is a longitudinal observation study. It included 200 women scoring ≥ 13 with the Edinburgh Postpartum Depression Scale, indicating presence of symptoms of depression. They had a gestational age of ≥ 6 wk and did follow-ups until the 10^th week to 12^th weeks postpartum. Information of women's reactions to life circumstances and stressors during the current pregnancy were gathered from answers to questions of the designed unstructured clinical questionnaire. Severities of depression, anxiety, and parenting stress were determined by the Beck Depre-ssion Inventory, State-Trait Anxiety Inventory for Adults, and Parenting Stress Index-Short Form, respectively. Psychiatric interviewing was done to confirm the diagnosis of major depression. Measuring the levels of triiodothronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH) was done in both antepartum and postpartum periods.

RESULTS

Out of 968 (mean age = 27.35 ± 6.42 years), 20.66% (n = 200) of the patients had clinically significant symptoms of depression and 7.44% had major depression. Previous premenstrual dysphoria, post-abortive depression, and depression unrelated to pregnancy and were reported in 43%, 8%, and 4.5% of the patients, respectively. Psychosocial stressors were reported in 15.5% of the patients. Antepartum anxiety and parenting stress were reported in 90.5% and 65% of the patients, respectively. Postpartum T3, T4, and TSH levels did not significantly differ from reference values. Regression analysis showed that anxiety trait was a predictor for antepartum (standardized regression coefficients = 0.514, t = 8.507, P = 0.001) and postpartum (standardized regression coefficients = 0.573, t = 0.040, P = 0.041) depression. Antepartum depression (standardized regression coefficients = -0.086, t = -2.750, P = 0.007), and parenting stress (standardized regression coefficients = 0.080, t = 14.34, P = 0.0001) were also predictors for postpartum depression.

CONCLUSION

Results showed that 20.66% of the patients had clinically significant symptoms of depression and 7.44% had major depression. Anxiety was a predictor for antepartum and postpartum depression. Antepartum depression and parenting stress were also predictors for postpartum depression.

Perinatal mental illness and maternal autoimmune disease: A review of current evidence and avenues for future research

This review summarizes evidence on the association between perinatal mental illness and maternal autoimmune disease and identifies avenues for future research. Perinatal mental illness has several characteristics in common with autoimmune disease, including increased incidence in the early postpartum period, recurrence across pregnancies, evidence of elevated immune-mediated cytokines, and familial risk, as well as the general predominance of mental illness in females versus males. Several studies have demonstrated elevated risk of maternal autoimmune disease in women with perinatal mental illness, and of perinatal mental illness in those with autoimmune dysfunction, suggesting a bi-directional relationship. Further research is needed to elucidate the importance of the specific diagnosis, severity, and timing of perinatal mental illness and specific diagnosis of autoimmune disease, as well as the relative importance of perinatal versus non-perinatal mental illness. Such research could have implications for prevention, treatment, and follow-up of perinatal mental illness.

Postpartum depression in maternal thyroidal changes

Evidence in the literature has suggested that there may be an association between thyroid antibodies and depression during pregnancy and in the postpartum period. Thus, this study aims to conduct a systematic review on the prevalence of postpartum depression (PPD) in women with thyroid abnormalities during pregnancy or in the postpartum period. For this review, we used four databases (PubMed, Lilacs, Scielo, and Scopus). Fifteen studies were selected; one study used a case–control design, four used a cross-sectional design and ten utilized prospective cohort designs. All studies were restricted to up to 1 year postpartum, and 46.7% focused on a period between immediate postpartum and 6 months postpartum. Estimates of the prevalence of PPD in pregnant women with thyroid disorders ranged between 8.3% and 36.0%. For follow-up studies, the cumulative incidence of self-reported depression from the primary episode in the first postpartum year was 6.3% in a high-city survey. Although some authors consider the status of positive anti-TPO antibodies to be a possible marker of vulnerability to depression , it is not yet possible to conclude whether thyroid function in the pregnancy-puerperal cycle is involved with the development of PPD.

[Clinical and psychopatological features of endogenous depressions in young women]

OBJECTIVE

To study the features of psychopatological structure of endogenous depression in young women and to identify correlations between various clinical types of depression and their nosological affilation.

MATERIAL AND METHODS

The results of clinical/psychopathological examination of 107 female patients, aged 16 to 25 years, with endogenous depression with one of the following ICD-10 diagnosis: (F34.0; F31.3-F31.5; F21.3-F.21.4+F31.3-F31.5; F60.X+F31.3-F31.5) were analyzed.

RESULTS

Several types of endogenous depression were identified: 1) hysterical depression with hysterical-conversions, and also the phenomena of delusional fantasies; 2) dysmorphic depression with predominance of over-valued ideas of physical disability, self-inferiority and eating disorder; 3) depersonalization depression with depersonalization-derealization symptoms; 4) psychopath-like depression with exaggerated behavior, opposition and impulsivity; 5) existential depression with a feeling of losing the life meaning and often pessimistic worldview; 6) psychasthenic depression with the low self-esteem and exaggerated introspection combined with obsessive-phobic disorder; 7) anxious-melancholic depression with anxiety, melancholy and ideas of self-accusation and self-inferiority; 8) depression with symptoms of adolescent asthenic insolvency with difficulties of understanding information, increasing intellectual exhaustion. We revealed differences in motives for committing non-suicidal self-harm behavior and suicidal behavior in typological variants of depressions.

CONCLUSION

Hysteroform and psychopathic depressions prevail in personality disorders, while psychosthenic-like, anxious-melancholic and existential depressions are more frequent in affective disorders. Depersonalization depressions are more common in schizotypal disorder. When comparing the types of depressions in boys as reported in previous research with those in girls, the prevalence of hysteroform and anxious-melancholic variants in girls is revealed.

Association between the serum insulin-like growth factor-1 concentration in the first trimester of pregnancy and postpartum depression

AIM

Patients with major depression present with an increased serum insulin-like growth factor-1 (IGF-1) concentration. However, the longitudinal relationship between serum IGF-1 levels and depression development remains unclear. This study aimed to investigate the longitudinal association between the serum IGF-1 concentration in the first trimester of pregnancy and postpartum depression development using data obtained from the Japan Environment and Children's Study (JECS).

METHODS

The JECS included 97 415 pregnant women; among them, 8791 were enrolled in this study. Data regarding depression in the first trimester, postpartum depression development at 1 month after childbirth, and other covariates were collected using a self-administered questionnaire. Serum IGF-1 levels were measured in the first trimester of pregnancy. The participants were divided into four groups according to the serum IGF-1 level.

RESULTS

In the first trimester, serum IGF-1 levels were not significantly associated with psychological distress in pregnant women. In the longitudinal analyses, however, postpartum depression development in mothers within the highest quartile for serum IGF-1 concentration in the first trimester was significantly less common than in those within the lowest quartile (odds ratio 0.48, 95% confidence interval 0.30-0.79).

CONCLUSION

Pregnant women with a high serum IGF-1 concentration in the first trimester were less likely to develop postpartum depression than those with a low concentration. A high serum IGF-1 concentration during pregnancy may help to protect against postpartum depression development.

A systematic review of cortisol, thyroid-stimulating hormone, and prolactin in peripartum women with major depression

Pregnancy and postpartum are periods of high susceptibility to major depression (MD) and other mood disorders. The peripartum period is also a time of considerable changes in the levels of hormones, including cortisol, thyroid-stimulating hormone (TSH), prolactin, gonadotropins, and gonadal steroids. To investigate the relationship between mood and hormonal changes during and after pregnancy, we reviewed published reports of hormonal measures during this time frame, searched via PubMed and Web of Science. Studies were included if women in the antepartum or postpartum periods were clinically diagnosed with MD, and if there were repeated measures of cortisol, TSH, or prolactin. For these three hormones, the numbers of human studies that met these criteria were 15, 7, and 3, respectively. Convergent findings suggest that morning cortisol is reduced in pregnant and postpartum women with MD. Evidence did not support changes in TSH as a marker of MD during the peripartum period, and evidence for changes in prolactin in peripartum MD was equivocal. Aside from reduced morning cortisol in peripartum women with MD, definitive evidence for an association between specific hormonal fluctuations and mood disorders in the peripartum period remains elusive.

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

BACKGROUND

Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.

Autoimmune Abnormalities of Postpartum Thyroid Diseases

The year following parturition is a critical time for the de novo appearance or exacerbation of autoimmune diseases, including autoimmune thyroid disease. The vast majority of postpartum thyroid disease consists of postpartum thyroiditis (PPT) and the minority by Graves' disease and non-autoimmune thyroiditis. PPT has a worldwide prevalence ranging from 1 to 22% and averaging 5% based on a review published in 2012. Several factors confer risk for the development of PPT. Typically, the clinical course of PPT is characterized by three phases: thyrotoxic, hypothyroid, and euthyroid phase. Approximately half of PPT women will have permanent hypothyroidism. The best humoral marker for predictivity, already during the first trimester of gestation, is considered positivity for thyroperoxidase autoantibodies (TPOAb), though only one-third to half of such TPOAb-positive pregnant women will develop PPT. Nutraceuticals (such as selenium) or omega-3-fatty acid supplements seem to have a role in prevention of PPT. In a recent study on pregnant women with stable dietary habits, we found that the fish consumers had lower rates of positivity (and lower serum levels) of both TPOAb and thyroglobulin Ab compared to meat eaters. Finally, we remind the reader of other diseases that can be observed in the postpartum period, either autoimmune or non-autoimmune, thyroid or non-thyroid.

Decreased anxiety- and depression-like behaviors and hyperactivity in a type 3 deiodinase-deficient mouse showing brain thyrotoxicosis and peripheral hypothyroidism

Hypo- and hyperthyroid states, as well as functional abnormalities in the hypothalamic-pituitary-thyroid axis have been associated with psychiatric conditions like anxiety and depression. However, the nature of this relationship is poorly understood since it is difficult to ascertain the thyroid status of the brain in humans. Data from animal models indicate that the brain exhibits efficient homeostatic mechanisms that maintain local levels of the active thyroid hormone, triiodothyronine (T3) within a narrow range. To better understand the consequences of peripheral and central thyroid status for mood-related behaviors, we used a mouse model of type 3 deiodinase (DIO3) deficiency (Dio3 -/- mouse). This enzyme inactivates thyroid hormone and is highly expressed in the adult central nervous system. Adult Dio3 -/- mice exhibit elevated levels of T3-dependent gene expression in the brain, despite peripheral hypothyroidism as indicated by low circulating levels of thyroxine and T3. Dio3 -/- mice of both sexes exhibit hyperactivity and significantly decreased anxiety-like behavior, as measured by longer time spent in the open arms of the elevated plus maze and in the light area of the light/dark box. During the tail suspension, they stayed immobile for a significantly shorter time than their wild-type littermates, suggesting decreased depression-like behavior. These results indicate that increased thyroid hormone in the brain, not necessarily in peripheral tissues, correlates with hyperactivity and with decreases in anxiety and depression-like behaviors. Our results also underscore the importance of DIO3 as a determinant of behavior by locally regulating the brain levels of thyroid hormone.

Thyroid peroxidase autoantibodies and perinatal depression risk: A systematic review

BACKGROUND

While thyroid autoantibodies have been linked to depression in general population samples, it is unclear if the immunological milieu of pregnancy alters this association. As a result, we systematically reviewed the literature to determine if abnormal levels of autoantibodies that target thyroperoxidase (TPO-AB) during the perinatal period are associated with an increased risk of antenatal and postnatal depression.

METHODS

MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched through February 2016. Primary studies that examined TPO-AB titers during pregnancy or the postpartum period, and antenatal or postnatal depression were eligible. The quality of each study was assessed using the Newcastle-Ottawa Scale.

RESULTS

Among the eleven articles selected for synthesis, three of these examined associations between TPO-AB and depression both during pregnancy and in the postpartum period. Three of five studies reported statistically significant associations between elevated TPO-AB titers (TPO-AB+) and concurrent depression at 12-25 weeks gestation. Four of five studies found significant associations between TPO-AB+ status at 12-25 weeks gestation and depression in the postpartum period. Two of four studies found links between postpartum TPO-AB and depression concurrently in the puerperium.

LIMITATIONS

Lack of adjustment for confounding variables limits causal inference and conclusions about the predictive power of TPO-AB.

CONCLUSIONS

Studies suggest that TPO-AB+ in early to mid-pregnancy is associated with concurrent depression and may be predictive of depression in the postpartum period. Future studies with improved methodology are required to better understand the full pathophysiological implications and predictive utility of TPO-AB in perinatal depression.

Thyroid disorders during pregnancy

Thyroid disorders are common in pregnancy and in nonpregnant women of childbearing age, but can be missed because of nonspecific symptoms and normal changes in thyroid gland physiology during pregnancy. The prevalence of overt hyperthyroidism complicating pregnancy has been reported to range between 0.4% and 1.7%, and an estimated 2% to 3% of women are hypothyroid during pregnancy. Abnormalities in maternal thyroid function are associated with complications during pregnancy, and may affect maternal and fetal outcomes. Thus it is important to identify thyroid disorders before pregnancy or early in pregnancy so that appropriate treatment can be initiated.

An update on subclinical hypothyroidism and subclinical hyperthyroidism

Subclinical thyroid dysfunction is characterized by normal levels of peripheral thyroid hormone, paired with a TSH level that is either lower than (subclinical hyperthyroidism) or higher than (subclinical hypothyroidism) the normal laboratory reference range. Slight shifts in peripheral hormone levels result in significant serum TSH changes. The exact upper limit of normal TSH and the management of subclinical hypothyroidism are still controversial. For those with TSH between high upper limit of normal and 10 mIU/L, the authors suggest selective use of thyroxine therapy. The authors agree with the general consensus in favor of therapy for those with serum TSH levels above 10 mIU/L. This recommendation is compatible with guidelines of American Thyroid Association and American Association of Clinical Endocrinologists. For subclinical hyperthyroidism persistent serum TSH <0.1 mIU/L should be treated particularly if the etiology is nodular toxic goiter. For serum TSH between 0.1 mIU/L and lower limit of normal, serum TSH co-morbidities such as cardiac risk factors and osteoporosis may favor therapy.

Prevention and treatment of postnatal depression

Postnatal depression is a common condition that may have a significant negative impact on both infant and mother, often remaining undiagnosed and untreated. Development of effective means of detection, prevention and treatment of postnatal depression is a major health challenge. The objective of this article is to critically review pharmacological, psychological and psychosocial approaches of prevention and treatment for postnatal depression. There is little evidence of short-term success for preventive interventions and some evidence of short-term success for treatment interventions. No preventive or therapeutic studies, however, have provided evidence for long-term success. There is a need for future research into the prevention and treatment of postnatal depression including the assessment of long-term effects on the child's development as well as feasibility in relation to cost-effectiveness.

Thyroid disorders during pregnancy

Thyroid disorders are common in women during pregnancy. If left untreated, both hypothyroidism and hyperthyroidism are associated with adverse effects on pregnancy and fetal outcomes. It is important to correctly identify these disorders and treat them appropriately to prevent pregnancy-related complications. Levothyroxine is the indicated treatment for hypothyroidism, and thionamides are the treatment of choice for hyperthyroidism; thyroidectomy may be indicated in select cases. When thyroid cancer is diagnosed during pregnancy, a decision must be made regarding performing thyroidectomy during the pregnancy or postponing surgical resection until the postpartum period. Radioactive iodine is absolutely contraindicated during pregnancy and lactation.

What the obstetrician/gynecologist should know about thyroid disorders

Thyroid disease is a common disorder faced by women of all ages. Because of its high incidence in women, recognizing and treating thyroid dysfunction often becomes the responsibility of the obstetrician/gynecologist. It is important that women's healthcare providers understand how the thyroid's function changes as a woman enters her reproductive years, as well as during pregnancy and menopause. Current guidelines for diagnosing and managing thyroid dysfunction and recommended treatment strategies are discussed in this review.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this educational activity, the obstetrician/gynecologist should be better able to evaluate normal thyroid physiology and pathophysiology of thyroid dysfunction; assess appropriate screening options for their patients; and diagnose and manage thyroid disorders common among reproductive-aged women.

Thyroid autoimmunity and treatment response to escitalopram in major depression

BACKGROUND

There is evidence that immune alterations play an important part in the pathogenesis of major depression. Thyroid autoimmunity has been found in association with major depression in several studies.

AIM

1) to examine whether the prevalence of anti-thyroid peroxidase autoantibodies (anti-TPO) in depressive patients differs from that in healthy controls; 2) to investigate the possible relationship between thyroid autoimmunity, total T3, free T3, free T4, thyroid-stimulating hormone (TSH), clinical status and treatment outcome in depression.

METHOD

The study group consisted of 129 outpatients (69.8% female; mean age 31.7+/-12.0 years) with major depressive disorder with a Montgomery-Azsberg Depression Rating Scale total score of 22 or higher and 72 healthy controls (62.5% female; mean age 31.7+/-13.1 years). The patients were treated with escitalopram 10-20 mg/day for 12 weeks using open-label placebo non-controlled design. Anti-TPO, total T3, free T3, free T4 and TSH were measured before the treatment.

RESULTS

The anti-TPO was found in eight (8.9%) depressive and two (4.8%) healthy females without statistical difference between these groups. Since anti-TPO was not seen in males, all further statistical analyses were carried out in females. At the end of week 12 of the treatment, 60 female patients (66.7%) were defined as responders and 30 depressive females (33.3%) showed insufficient response to treatment. Although there were no significant differences in the measurements between responders and non-responders, the last group showed a trend for a higher prevalence of anti-TPO compared with responders.

CONCLUSION

Thyroid autoimmunity might be a factor predicting treatment response to antidepressants in depressive patients.

Thyroid function 48h after delivery as a marker for subsequent postpartum depression

Physiological changes during gestation and after delivery are associated with postpartum thyroid dysfunction, which is due to thyroid autoimmunity in some cases. Postpartum thyroid dysfunction, in turn, has been associated with postpartum depression (PPD). The aim of the present study was to evaluate whether thyroid function immediately after delivery can predict postpartum depression at 8 weeks and 32 weeks after delivery. This study examined 1053 postpartum Spanish women without a previous history of depression. We evaluated depressive symptoms at 48h, 8 weeks and 32 weeks postpartum and used a diagnostic interview to confirm major depression for all probable cases. Free thyroxin (fT4), thyroid-stimulating hormone (TSH), thyroid peroxidase antibodies (TPOAb) and C-reactive protein (CRP) were assayed at 48h postpartum. Binary and multivariate logistic regression analyses were performed to determine independent risk factors for PPD. Although 152 women (14.4%) had high TPOAb (>27IU/mL) and slightly elevated TSH concentrations with normal fT4, we did not find any association between thyroid function and PPD. This thyroid dysfunction was not associated with CRP concentrations that were outside of the normal range (>3mg/L). We conclude that thyroid function at 48h after delivery does not predict PPD susceptibility.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Postpartum fatigue and evidence-based interventions

The aim of this article is to review postpartum fatigue, especially as it relates to the occurrence and pathophysiology of three common postpartum conditions known to contribute to fatigue: anemia, infection/inflammation, and thyroid dysfunction. Fatigue is an unrelenting condition that affects physical and mental health, and it has implications for everyday activities, motivation, and social interactions. Although individuals of all ages and both genders are at risk for developing fatigue, postpartum fatigue is particularly challenging, because the new mother has demanding life tasks to accomplish during this period of time. Postpartum fatigue may impact postpartum maternal role attainment and may place a woman at increased risk for postpartum depression. Although several treatable physiological conditions common during the postpartum period are known to increase fatigue, none of these conditions is a part of the usual assessment of healthy postpartum women. For many women, subtle fatigue may develop, linger or worsen, and even lead to depression, with both the woman and her care provider unaware.

Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society Clinical Practice Guideline

OBJECTIVE

The objective is to provide clinical guidelines for the management of thyroid problems present during pregnancy and in the postpartum.

PARTICIPANTS

The Chair was selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society. The Chair requested participation by the Latin American Thyroid Society, the Asia and Oceania Thyroid Society, the American Thyroid Association, the European Thyroid Association, and the American Association of Clinical Endocrinologists, and each organization appointed a member to the task force. Two members of The Endocrine Society were also asked to participate. The group worked on the guidelines for 2 yr and held two meetings. There was no corporate funding, and no members received remuneration.

EVIDENCE

Applicable published and peer-reviewed literature of the last two decades was reviewed, with a concentration on original investigations. The grading of evidence was done using the United States Preventive Services Task Force system and, where possible, the GRADE system.

CONSENSUS PROCESS

Consensus was achieved through conference calls, two group meetings, and exchange of many drafts by E-mail. The manuscript was reviewed concurrently by the Society's CGS, Clinical Affairs Committee, members of The Endocrine Society, and members of each of the collaborating societies. Many valuable suggestions were received and incorporated into the final document. Each of the societies endorsed the guidelines.

CONCLUSIONS

Management of thyroid diseases during pregnancy requires special considerations because pregnancy induces major changes in thyroid function, and maternal thyroid disease can have adverse effects on the pregnancy and the fetus. Care requires coordination among several healthcare professionals. Avoiding maternal (and fetal) hypothyroidism is of major importance because of potential damage to fetal neural development, an increased incidence of miscarriage, and preterm delivery. Maternal hyperthyroidism and its treatment may be accompanied by coincident problems in fetal thyroid function. Autoimmune thyroid disease is associated with both increased rates of miscarriage, for which the appropriate medical response is uncertain at this time, and postpartum thyroiditis. Fine-needle aspiration cytology should be performed for dominant thyroid nodules discovered in pregnancy. Radioactive isotopes must be avoided during pregnancy and lactation. Universal screening of pregnant women for thyroid disease is not yet supported by adequate studies, but case finding targeted to specific groups of patients who are at increased risk is strongly supported.

Postpartum depression, an autoimmune disease?

Medical conditions with known etiology and typical peripartal/postpartal disease exacerbations are now, without exception, considered autoimmune in etiology. Postpartum psychiatric conditions, and especially postpartum depression, currently, however, are still not understood in their etiology. This paper suggests that the typical postpartum flare pattern, and other clinical characteristics, point towards an autoimmune etiology for (postpartum) depression. The high prevalence of (postpartum) depression led to its designation as a major public health problem. A better understanding of etiology and pathophysiology would greatly advance the, currently still inaccurate, diagnosis of the condition, and improve approaches towards prevention and treatment.

Antenatal thyroid correlates of postpartum depression

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

Peripheral thyroid dysfunction in depression

The involvement of the thyroid gland and thyroid hormones is generally believed to be important in the aetiopathogenesis of major depression. Major support comes from studies in which alterations in components of the hypothalamic-pituitary-thyroid (HPT) axis have been documented in patients with primary depression. However, screening thyroid tests are often routine and add little to the diagnostic evaluation. Overt thyroid disease is rare among depressed inpatients. The finding that depression often co-exists with autoimmune subclinical thyroiditis suggests that depression may cause alterations in the immune system, or that in fact it could be an autoimmune disorder itself. The outcome of treatment and the course of depression may be related to thyroid status as well. Augmentation of antidepressant therapy with the co-administration of thyroid hormones (mainly T3) is a well-documented treatment option for refractory depressed patients. Review of the literature suggests that there are no conclusive data on the role of thyroid function in depression. It is clear that depression is not characterised by an overt thyroid dysfunction, but it is also clear that a subgroup of depressed patients may manifest subtle thyroid abnormalities, or an activation of an autoimmune process. There is a strong possibility that the presence of a subtle thyroid dysfunction is a negative prognostic factor for depression and may demand specific therapeutic intervention.

Perinatal depression: a systematic review of prevalence and incidence

OBJECTIVE

We systematically review evidence on the prevalence and incidence of perinatal depression and compare these rates with those of depression in women at non-childbearing times.

DATA SOURCES

We searched MEDLINE, CINAHL, PsycINFO, and Sociofile for English-language articles published from 1980 through March 2004, conducted hand searches of bibliographies, and consulted with experts.

METHODS OF STUDY SELECTION

We included cross-sectional, cohort, and case-control studies from developed countries that assessed women for depression during pregnancy or the first year postpartum with a structured clinical interview.

TABULATION, INTEGRATION, AND RESULTS

Of the 109 articles reviewed, 28 met our inclusion criteria. For major and minor depression (major depression alone), the combined point prevalence estimates from meta-analyses ranged from 6.5% to 12.9% (1.0-5.6%) at different trimesters of pregnancy and months in the first postpartum year. The combined period prevalence shows that as many as 19.2% (7.1%) of women have a depressive episode (major depressive episode) during the first 3 months postpartum; most of these episodes have onset following delivery. All estimates have wide 95% confidence intervals, showing significant uncertainty in their true levels. No conclusions could be made regarding the relative incidence of depression among pregnant and postpartum women compared with women at non-childbearing times.

CONCLUSION

To better delineate periods of peak prevalence and incidence for perinatal depression and identify high risk subpopulations, we need studies with larger and more representative samples.

Prevalence of pre- and postpartum depression in Jamaican women

BACKGROUND

Maternal depression during pregnancy has been studied less than depression in postpartum period. The aims of this study were to find out the prevalence of prepartum and postpartum depression and the risk factors associated in a cohort of Afro-Jamaican pregnant women in Jamaica.

METHODS

The Zung self-rating depression scale instrument was administered to 73 healthy pregnant women at 28 weeks gestation and at 6 weeks postpartum for quantitative measurement of depression. Blood samples were collected at 8, 28, 35 weeks gestation and at day 1 and 6 weeks postpartum to study the thyroid status.

RESULTS

Study demonstrated depression prevalence rates of 56% and 34% during prepartum and postpartum period, respectively. 94% women suffering depression in both periods were single. There were significant variations in both FT3 and TT4 concentrations which increased from week 8 to week 28 prepartum (p < 0.05) and then declined at the 35th week (p < 0.05 compared with week 28) and 1 day post delivery study (p < 0.05 compared with week 35). The mean values for TSH increased significantly from week 8 through week 35. The mean values at 1 day postpartum and 6 week postpartum were not significantly different from the 35 week values. For FT3, TT4 and TSH there were no significant between group differences in concentrations. The major determinants of postpartum depression were moderate and severe prepartum depression and change in TT4 hormone concentrations.

CONCLUSION

High prevalence of depression was found during pre- and postpartum periods. Single mothers, prepartum depression and changes in TT4 were factors found to be significantly associated with postpartum depression.

Symptoms of postpartum depression and breastfeeding

Despite important health benefits, the presence of depressive symptoms may decrease the prevalence of breastfeeding. The current study assessed the relationship between depressive symptoms and breastfeeding at 6 and 12 weeks postpartum. Participants were recruited from a cohort completing a clinical trial of calcium for prevention of preeclampsia. At 6 weeks postpartum, the Edinburgh Postnatal Depression Scale (EPDS) was completed by mail. At 12 weeks postpartum, the EPDS was completed at an outpatient visit. There was an inverse relationship between depressive symptoms and breastfeeding at 6 weeks postpartum (P<.001) but not at 12 weeks. This relationship persisted even after controlling for prior history of depression, increased life stress, and current psychoactive medication. The results suggest that depressive symptoms early in the postpartum period may lower the prevalence of breastfeeding.

Postpartum thyroiditis: long-term follow-up

OBJECTIVE

To determine the incidence of persistent hypothyroidism (PH) after a long follow-up in 45 patients with postpartum thyroiditis (PPT) from a nonselected population of 641 pregnant women (PPT incidence 7.8%) and the clinical and biochemical factors associated with PPT evolution.

DESIGN AND PATIENTS

The 45 women who developed PPT were followed for 8.1 +/- 2.2 years after delivery.

MEASUREMENTS

Age at delivery, family and personal history, smoking, newborn gender, breast-feeding, and PPT course were recorded. Thyrotropin (TSH) and free thyroxine (T(4)) concentrations and antithyroid antibodies were evaluated at each visit. PH was considered when it persisted one year after being diagnosed.

RESULTS

Fourteen of 45 patients with PPT developed PH with a probability of 56% after a PPT episode with hypothyroidism. None of the patients who developed hyperthyroidism alone during PPT evolved to PH. PH risk was higher if the newborn was a girl (relative risk [RR] 3.88) and increased for each additional TSH unit during PPT and for every additional year of the mother's age.

CONCLUSIONS

The probability of developing PH after a PPT with hypothyroidism episode is 56%. PPT screening in all women permits us to establish levothyroxine treatment, if necessary, before a new pregnancy.

Thyroid function in clinical subtypes of major depression: an exploratory study

BACKGROUND

Unipolar depression might be characterized by a 'low-thyroid function syndrome'. To our knowledge, this is the first study which explores the possible relationship of DSM-IV depressive subtypes and the medium term outcome, with thyroid function.

MATERIAL

Thirty major depressive patients (DSM-IV) aged 21-60 years and 60 control subjects were included. Clinical Diagnosis: The SCAN v 2.0 and the IPDE were used. The psychometric Assessment included HDRS the HAS and the GAF scales. Free-T3, Free-T4, TSH, Thyroid Binding Inhibitory Immunoglobulins (TBII), Thyroglobulin antibodies (TA) and Thyroid Microsomal Antibodies (TMA) were measured in the serum. The Statistical analysis included 1 and 2-way MANCOVA, discriminant function analysis and Pearson Product Moment Correlation Coefficient.

RESULTS

All depressive subtypes had significantly higher TBII levels in comparison to controls. Atypical patients had significantly higher TMA in comparison to controls. No significant correlation was observed between the HDRS, HAS and GAF scales and thyroid indices. Discriminant function analysis produced functions based on thyroid indices, which could moderately discriminate between diagnostic groups, but could predict good response to treatment with 89.47% chance of success.

CONCLUSION

Although overt thyroid dysfunction is not common in depression, there is evidence suggesting the presence of an autoimmune process affecting the thyroid gland in depressive patients

Gender differences in unipolar depression: an update of epidemiological findings and possible explanations

OBJECTIVE

To give an update on epidemiological findings on sex differences in the prevalence of unipolar depression and putative risk factors.

MATERIAL AND METHODS

Systematic review of the literature.

RESULTS

Recent epidemiological research yields additional evidence for a female preponderance in unipolar depression, holding true across different cultural settings. Current explanations include artefacts, genetic, hormonal, psychological and psychosocial risk factors. Rather consistently, intrapsychic and psychosocial gender role related risk factors have been identified which may contribute to the higher depression risk in women. Gender role aspects are also reflected in endocrine stress reactions and possibly influence associated neuropsychological processes.

CONCLUSION

There is a need for more integrative models taking into account psychological, psychosocial, and macrosocial risk factors as well as their interactions, which also connect these factors with physiological and endocrine responses. Furthermore, it is conceivable that across the life span, as well as across cultural settings, individual risk factors will add with varying emphasis to the higher prevalence of depression in women.