Influence of postpartum onset on the course of mood disorders

Longitudinal neuroanatomical increases from early to one-year postpartum

Preclinical studies have provided causal evidence that the postpartum period involves regional neuroanatomical changes in 'maternal' brain regions to support the transition to offspring caregiving. Few studies, in humans, have examined neuroanatomical changes from early to one-year postpartum with longitudinal neuroimaging data and their association with postpartum mood changes. In the present study, we examined longitudinal changes in surface morphometry (cortical thickness and surface area) in regions previously implicated in the transition to parenthood. We also examined longitudinal volumetric neuroanatomical changes in three subcortical regions of the maternal brain: the hippocampus, amygdala, and ventral diencephalon. Twenty-four participants underwent longitudinal structural magnetic resonance imaging at 1-4 weeks and 1 year postpartum. Cortical thickness increased from early to one-year postpartum in the left (p = .003, Bonferroni corrected) and right (p = .02, Bonferroni corrected) superior frontal gyrus. No significant increases (or decreases) were observed in these regions for surface area. Volumetric increases, across the postpartum period, were found in the left amygdala (p = .001, Bonferroni corrected) and right ventral diencephalon (p = .01, Bonferroni corrected). An exploratory analysis of depressive symptoms found reductions in depressive symptoms from early postpartum to one-year postpartum were associated with greater cortical thickness in the superior frontal gyrus for both the left (p = .02) and right (p = .02) hemispheres. The findings expand our evidence of the neuroanatomical changes that occur across the postpartum period in humans and motivate future studies to examine how mood changes across this period are associated with cortical thickness of the superior frontal gyrus.

Longitudinal Neuroanatomical Increases from Early to One-Year Postpartum

Preclinical studies have provided causal evidence that the postpartum period involves regional neuroanatomical changes in 'maternal' brain regions to support the transition to offspring caregiving. Few studies, in humans, have examined neuroanatomical changes from early to one-year postpartum with longitudinal neuroimaging data and their association with postpartum mood changes. In this study, we examined longitudinal changes in surface morphometry (cortical thickness and surface area) in regions previously implicated in the transition to parenthood. We also examined longitudinal volumetric neuroanatomical changes in three subcortical regions of the maternal brain: the hippocampus, amygdala, and ventral diencephalon. Twenty-four participants underwent longitudinal structural magnetic resonance imaging at 2-4 weeks and 1 year postpartum. Cortical thickness increased from early to one-year postpartum in the left (p = .003, Bonferroni corrected) and right (p = .02, Bonferroni corrected) superior frontal gyrus. No significant increases (or decreases) were observed in these regions for surface area. Volumetric increases, across the postpartum period, were found in the left amygdala (p = .001, Bonferroni corrected) and right ventral diencephalon (p = .01, Bonferroni corrected). An exploratory analysis of depressive symptoms found reductions in depressive symptoms from early postpartum to one-year postpartum were associated with greater cortical thickness in the superior frontal gyrus for both the left (p = .02) and right (p = .02) hemispheres. The findings expand our evidence of the neuroanatomical changes that occur across the postpartum period in humans and motivate future studies to examine how mood changes across this period are associated with cortical thickness of the superior frontal gyrus.

Postpartum Psychosis: A Proposed Treatment Algorithm

Background

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

Methods

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

Objective

To provide a treatment algorithm for the management of PPP based on available evidence.

Results

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

Conclusion

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.Reprinted from J Psychopharmacol 2023; 37:960-970, with permission from Sage Journals. Copyright © 2023.

Postpartum psychosis: A proposed treatment algorithm

BACKGROUND

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

METHODS

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

OBJECTIVE

To provide a treatment algorithm for the management of PPP based on available evidence.

RESULTS

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

CONCLUSION

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.

Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors

ABSTRACT

Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.

Acute Maternal Stress Disrupts Infant Regulation of the Autonomic Nervous System and Behavior: A CASP Study

Exposure to maternal stress is assumed to influence infant health and development across the lifespan. The autonomic nervous system (ANS) is especially sensitive to the effects of the early caregiving environment and linked to predictors of later mental health. Understanding how exposure to maternal stress adversely affects the developing ANS could inform prevention. However, there is no agreed upon definition of maternal stress making its study difficult. Here we use the Caretaker Acute Stress Paradigm (CASP) to study the effects of maternal stress in an experimentally controlled laboratory setting. The CASP has 5 episodes, a natural play, followed by a caretaker stressor (or control) condition, another play, a classic still face episode, followed by another play. A total of 104 4-months-old infants and their mothers were randomly assigned to either the caretaker-stress or caretaker-control condition. Changes in behavior, heart rate (HR), and respiratory sinus arrhythmia (RSA) before and after the introduction of the stressor (or control condition) were recorded and compared. Infants in the maternal stress condition showed significantly more behavioral distress [X 2 = (1, N = 104) = 4.662, p = 0.031]. Moreover, infants whose mothers were in the stress condition showed an significant increase in heart rate after the caretaker condition [F (1, 102) = 9.81, p = 0.002]. Finally we observed a trend to faster RSA recovery in infants of the control condition [F (1, 75) = 3.539, p = 0.064]. Results indicate that exposure to acute maternal stress affects infant regulation of the autonomic nervous system and behavior.

Clinical characteristics of bipolar disorders with postpartum depressive onset

BACKGROUND

Postpartum period is associated with an increased risk of bipolar disorder diagnosis and relapse, mainly major depressive episode. Onset during this period might be associated with specific characteristics.

AIM

To compare the socio-demographic and clinical characteristics of parous women presenting with bipolar disorder and an index depressive episode occurring during or outside the postpartum period.

METHODS

Using the multicenter cohort FACE-BD (FondaMental Academic Centers of Expertise for Bipolar Disorders), we considered all women who started their BD with a major depressive episode and have at least one child. We compared two groups depending on the onset: in or outside the postpartum period.

RESULTS

Among the 759 women who started BD with a major depressive episode, 93 (12.2%) had a postpartum onset, and 666 (87.8%) had not. Women who started BD in the postpartum period with a major depressive episode have a more stable family life, more children, an older age at onset, more Bipolar 2 disorder, less history of suicide attempts, less depressive episodes and more mood stabilizer treatments as compared to those who started with a major depressive episode outside the postpartum period. The multivariable logistic regression showed that women with an onset in the postpartum period had significantly more children, less lifetime depressive episodes and a lower rate of history of suicide attempts as compared to women with an onset outside the postpartum period.

DISCUSSION

Our results suggest that women starting their BD with postpartum depression have a more favorable course of BD, especially less history of suicide attempt and less lifetime depressive episodes.

A Caretaker Acute Stress Paradigm: Effects on behavior and physiology of caretaker and infant

While experimental stress paradigms of infants (arm restraint; the Still-Face) are powerful tools for infant research, no study has experimentally stressed mothers to observe its independent effects on infant stress regulation. Extant caretaker/maternal stress studies essentially are correlational and confounded by other conditions (e.g., depression). Here, we present a standard procedure, the Caregiver Acute Stress Paradigm (CASP), for stressing mothers during en face interactions with their infants. We hypothesized that infants of the stressed mothers would be more distressed than infants of non-stressed mothers. A total of 106 four-month-old infants and their mothers were randomly assigned to the experimental stress or non-stress manipulation. Confirming our hypothesis, infants of the stressed mothers were significantly more likely to become distressed and require terminating the procedure. While objective ratings of maternal behavior showed no difference between groups, mother in the stress condition self-rated the episode following the caretaker stress significantly lower than mothers in the non-stress group. The self-ratings in the maternal stress-group were reflected in infant cortisol. The findings indicate that CASP is an effective experimental paradigm for exploring the independent effects of an acute stress on caretakers, including effects of conditions, such as poverty or mental illness.

Bipolar postpartum depression: An update and recommendations

BACKGROUND

Over the past few years there has been a surge of interest in the study of bipolar postpartum depression (PPD); however, questions remain about its prevalence, screening, clinical features, and treatment.

METHODS

Three electronic databases, MEDLINE/PubMed (1966-2016), PsycINFO (1806-2016), and the Cochrane Database of Systematic Reviews, were searched using a combination of the keywords bipolar, depression, postpartum, peripartum, prevalence, screening, diagnosis, treatment, drugs, and psychotherapy. The reference lists of articles identified were also searched. All relevant articles published in English were included.

RESULTS

Depending on the population studied, 21.4-54% of women with PPD have a diagnosis of bipolar disorder (BD). Characteristic clinical features include younger age at illness onset, first onset of depression after childbirth, onset immediately after delivery, atypical depressive symptoms, psychotic features, mixed features, and history of BD in first-degree family members. Treatment should be guided by symptom acuity, safety concerns, the patient's response to past treatments, drug tolerability, and breastfeeding preference. In the absence of controlled treatment data, preference should be given to drugs normally indicated for bipolar depression including lithium, quetiapine and lamotrigine. Although antidepressants have been studied in combination with mood stabilizers in bipolar depression, these drugs should be avoided due to likelihood of elevated risk of induction of manic symptoms in the postpartum period.

CONCLUSIONS

In the postpartum period, bipolar PPD is common, can be differentiated from unipolar PPD, and needs to be identified promptly in order to expedite appropriate treatment. Future studies on pharmacotherapy and psychotherapy should focus on the acute and preventative treatment of bipolar PPD.

Maternal depression across the first years of life compromises child psychosocial adjustment; relations to child HPA-axis functioning

Maternal depression across the first years of life negatively impacts children's development. One pathway of vulnerability may involve functioning of the hypothalamic-pituitary-adrenal (HPA) axis. We utilize a community cohort of 1983 women with no comorbid risk repeatedly assessed for depression from birth to six years to form two groups; chronically depressed (N=40) and non-depressed (N=91) women. At six years, mother and child underwent psychiatric diagnosis, child salivary cortisol (CT) was assessed three times during a home-visit, mother-child interaction was videotaped, and child empathy was coded from behavioral paradigms. Latent Growth curve Model using Structural Equation Modeling (SEM) estimated the links between maternal depression and mother's negative parenting and three child outcomes; psychopathology, social withdrawal, and empathy as related to child CT baseline and variability. Depressed mothers displayed more negative parenting and their children showed more Axis-I psychopathology and social withdrawal. SEM analysis revealed that maternal depression was associated with reduced CT variability, which predicted higher child psychopathology and social withdrawal. Whereas all children exhibited similar initial levels of CT, children of controls reduced CT levels over time while children of depressed mothers maintained high, non-flexible levels. Mother negativity was related to lower initial CT levels, which predicted decreased empathy. Findings suggest that chronic maternal depression may compromise children's social-emotional adjustment by diminishing HPA-system flexibility as well as limiting the mother's capacity to provide attuned and predictable caregiving.

Oxytocin administration to parent enhances infant physiological and behavioral readiness for social engagement

BACKGROUND

The social milieu provides the context for the organism's survival, endurance, and adaptation. In mammals, social participation originates within the parent-infant bond and is supported by the oxytocin (OT) system, whose functioning is transmitted from parent to child through patterns of parental care. Human studies indicate that OT administration increases affiliative behavior, including trust, empathy, and social reciprocity. Here, we examine whether OT administration to parent can enhance physiological and behavioral processes that support parental social engagement but, moreover, can have parallel effects on the infant.

METHODS

Utilizing a double-blind, placebo-controlled crossover design, 35 fathers and their 5-month-old infants were observed twice following administration of OT or placebo to father in the face-to-face still-face paradigm. Parent and infant salivary OT were assessed at multiple time points, respiratory sinus arrhythmia (RSA) was measured in the three face-to-face still-face episodes, and social behaviors of the parent and child were micro-coded for indices of social engagement.

RESULTS

Oxytocin administration increased father salivary OT, RSA during free play, and key parenting behaviors that support parental-infant bonding. Parallel increases were also found in the infant's salivary OT, RSA response, and engagement behavior, including social gaze, exploration, and social reciprocity.

CONCLUSIONS

Results are the first to demonstrate that OT administration to one attachment partner can have parallel effects on the other and underscore the role of OT in the cross-generation transmission of human social participation. Findings have translational implications for conditions associated with early risk for social-emotional growth, including autism and prematurity, without the need to administer drugs to young infants.

Oxytocin and social affiliation in humans

A conceptual model detailing the process of bio-behavioral synchrony between the online physiological and behavioral responses of attachment partners during social contact is presented as a theoretical and empirical framework for the study of affiliative bonds. Guided by an ethological behavior-based approach, we suggest that micro-level social behaviors in the gaze, vocal, affective, and touch modalities are dynamically integrated with online physiological processes and hormonal response to create dyad-specific affiliations. Studies across multiple attachments throughout life are presented and demonstrate that the extended oxytocin (OT) system provides the neurohormonal substrate for parental, romantic, and filial attachment in humans; that the three prototypes of affiliation are expressed in similar constellations of social behavior; and that OT is stable over time within individuals, is mutually-influencing among partners, and that mechanisms of cross-generation and inter-couple transmission relate to coordinated social behavior. Research showing links between peripheral and genetic markers of OT with concurrent parenting and memories of parental care; between administration of OT to parent and infant's physiological readiness for social engagement; and between neuropeptides and the online synchrony of maternal and paternal brain response in social-cognitive and empathy networks support the hypothesis that human attachment develops within the matrix of biological attunement and close behavioral synchrony. The findings have conceptual implications for the study of inter-subjectivity as well as translational implications for the treatment of social disorders originating in early childhood, such as autism spectrum disorders, or those associated with disruptions to early bonding, such as postpartum depression or child abuse and neglect. This article is part of a Special Issue entitled Oxytocin, Vasopressin, and Social Behavior.

The experience of labor, maternal perception of the infant, and the mother's postpartum mood in a low-risk community cohort

Postpartum negative mood interferes with maternal-infant bonding and carries long-term negative consequences for infant growth. We examined the effects of birth-related risks on mother's postpartum anxiety and depression. A community cohort of 1,844 low-risk women who delivered a singleton term baby completed measures assessing delivery, emotions during labor, attitudes toward pregnancy and infant, mood regulation, and postpartum anxiety and depression. Under conditions of low risk, 20.5% of parturient women reported high levels of depressive symptoms. Following Cesarean Section Delivery (CSD), 23% reported high depressive symptoms, compared to 19% following Vaginal Delivery (VGD), and 21% after Assisted Vaginal Delivery (AVGD). State anxiety was highest in CSD and lowest in VGD. Mothers undergoing CSD experienced labor as most negative, reported highest somatic symptoms during the last trimester, and were least efficient in regulating negative mood. Postpartum depression was independently associated with higher maternal age, CSD, labor pain, lower negative and higher positive emotions during labor, inefficient mood regulation, somatic symptoms, and more negative and less positive perception of fetus during last trimester. Results demonstrate that elevated depressive symptoms are prevalent in the postpartum even under optimal socioeconomic and health conditions and increase following CSD. Interventions to increase positive infant-related perceptions and emotions may be especially important for promoting bond formation following CSD.

Exploring the Factors That Influence Functional Performance Among Nursing Home Residents

Objective: To promote healthy aging in older nursing home (NH) residents, it is important to identify factors that impact functional performance. Using the Disablement Process Model, it was hypothesized that variables from all levels of the model would significantly impact the ability of a NH resident to get up from a chair. Method: A stepwise multiple logistic regression model was used to test the impact of sociodemographic, physiologic, physical, psychosocial, and environmental factors on chair rise. Results: Analysis indicated that three factors, strength, gait, and self-efficacy, were significantly associated with chair-rise ability and together explained approximately 64% of the variance and successfully classified 88.4% of the chair-rise cases. Discussion: These findings indicate that identifying physical and psychosocial variables early in the disablement process will help health care providers tailor medical and restorative care interventions that may help older adults maintain the ability to chair rise.

Natural variations in maternal and paternal care are associated with systematic changes in oxytocin following parent-infant contact

Animal studies have demonstrated that the neuropeptide oxytocin (OT) plays a critical role in processes of parent-infant bonding through mechanisms of early parental care, particularly maternal grooming and contact. Yet, the involvement of OT in human parenting remains poorly understood, no data are available on the role of OT in the development of human fathering, and the links between patterns of parental care and the OT response have not been explored in humans. One hundred and twelve mothers and fathers engaged in a 15-min play-and-contact interaction with their 4-6-month-old infants and interactions were micro-coded for patterns of parental touch. Results showed that baseline levels of plasma and salivary OT in mothers and fathers were similar, OT levels in plasma and saliva were inter-related, and OT was associated with the parent-specific mode of tactile contact. Human mothers who provided high levels of affectionate contact showed an OT increase following mother-infant interaction but such increase was not observed among mothers displaying low levels of affectionate contact. Among fathers, only those exhibiting high levels of stimulatory contact showed an OT increase. These results demonstrate consistency in the neuroendocrine basis of human parental interactions with those seen in other mammals. The findings underscore the need to provide opportunities for paternal care to trigger the biological basis of fatherhood and suggest that interventions that permit social engagement may be recommended in conditions of diminished maternal-infant contact, such as prematurity or postpartum depression.

Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity

OBJECTIVE

To examine the effects of maternal depression on infant social engagement, fear regulation, and cortisol reactivity as compared with maternal anxiety disorders and controls and to assess the role of maternal sensitivity in moderating the relations between maternal depression and infant outcome.

METHOD

Using an extreme-case design, 971 women reported symptoms of anxiety and depression after childbirth and 215 of those at the high and low ends were reevaluated at 6 months. At 9 months, mothers diagnosed with a major depressive disorder (n = 22) and anxiety disorders (n = 19) and matched controls reporting no symptoms across the postpartum year (n = 59) were visited at home. Infant social engagement was observed during mother-infant interaction, emotion regulation was microcoded from a fear paradigm, and mother's and infant's cortisol were sampled at baseline, reactivity, and recovery.

RESULTS

The infants of depressed mothers scored the poorest on all three outcomes at 9 months-lowest social engagement, less mature regulatory behaviors and more negative emotionality, and highest cortisol reactivity-with anxious dyads scoring less optimally than the controls on maternal sensitivity and infant social engagement. Fear regulation among the children of anxious mothers was similar to that of the controls and their stress reactivity to infants of depressed mothers. Effect of major depressive disorder on social engagement was moderated by maternal sensitivity, whereas two separate effects of maternal disorder and mother sensitivity emerged for stress reactivity.

CONCLUSIONS

Pathways leading from maternal depression to infant outcome are specific to developmental achievement. Better understanding of such task-specific mechanisms may help devise more specifically targeted interventions.

Neural dysfunction in postpartum depression: an fMRI pilot study

INTRODUCTION

With approximately 4 million births each year in the United States, an estimated 760,000 women annually suffer from a clinically significant postpartum depressive illness. Yet even though the relationship between psychiatric disorders and the postpartum period has been documented since the time of Hippocrates, fewer than half of all these cases are recognized.

OBJECTIVE

Because postpartum depression (PPD), the most common complication of childbearing, remains poorly characterized, and its etiology remains unclear, we attempted to address a critical gap in the mechanistic understanding of PPD by probing its systems-level neuropathophysiology, in the context of a specific neurobiological model of fronto-limbic-striatal function.

METHODS

Using emotionally valenced word probes, with linguistic semantic specificity within an integrated functional magnetic resonance imaging (fMRI) protocol, we investigated emotional processing, behavioral regulation, and their interaction (functions of clinical relevance to PPD), in the context of fronto-limbic-striatal function.

RESULTS

We observed attenuated activity in posterior orbitofrontal cortex for negative versus neutral stimuli with greater PPD symptomatology, increased amygdala activity in response to negative words in those without PPD symptomotology, and attenuated striatum activation to positive word conditions with greater PPD symptomotology.

CONCLUSION

Identifying the functional neuroanatomical profile of brain systems involved in the regulation of emotion and behavior in the postpartum period will not only assist in determining whether the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric diagnostic specifier of PPD has an associated, unique, functional neuroanatomical profile, but a neurobiological characterization in relation to asymptomatic (postpartum non-depressed) control subjects, will also increase our understanding of the affective disorder spectrum, shed additional light on the possible mechanism(s) responsible for PPD and provide a necessary foundation for the development of more targeted, biologically based diagnostic and therapeutic strategies for PPD.