Adverse life events increase risk for postpartum psychiatric episodes: A population-based epidemiologic study

The Turkish version of the Postpartum Bonding Questionnaire (PBQ): Examination of the validity and reliability and scale structure

PURPOSE

The aim of this study is to investigate the validity and reliability of the Turkish version of the Postpartum Bonding Questionnaire (PBQ).

DESIGN AND METHODS

This methodological study was conducted with 250 women who presented to three family health centers in Istanbul/Turkey between April and June 2022 and met the sampling criteria. Validity analysis was performed using the content validity index, exploratory factor analysis, and confirmatory factor analysis. Pearson product-moment correlation and Cronbach Alpha reliability coefficients were used for reliability analysis.

RESULTS

To evaluate invariance of the instrument over time, test-retest measurements were conducted at least two weeks apart and showed no difference in mean scores (p > .05). Adjusted goodness-of-fit index >0.97 and comparative fit index >0.98 confirmed the construct validity of the Turkish PBQ. Each item had a content validity index of 96%. Corrected item-total score correlations ranged from 0.50 to 0.93. The Cronbach Alpha was found to be 0.96, indicating high internal consistency.

CONCLUSION

The results of this study show that the Turkish version of the PBQ is valid and reliable. It can be used as a measurement tool to determine the degree of maternal bonding in the postpartum period.

The bidirectional association between premenstrual disorders and perinatal depression: A nationwide register-based study from Sweden

BACKGROUND

Premenstrual disorders (PMDs) and perinatal depression (PND) share symptomology and the timing of symptoms of both conditions coincide with natural hormonal fluctuations, which may indicate a shared etiology. Yet, there is a notable absence of prospective data on the potential bidirectional association between these conditions, which is crucial for guiding clinical management. Using the Swedish nationwide registers with prospectively collected data, we aimed to investigate the bidirectional association between PMDs and PND.

METHODS AND FINDINGS

With 1,803,309 singleton pregnancies of 1,041,419 women recorded in the Swedish Medical Birth Register during 2001 to 2018, we conducted a nested case-control study to examine the risk of PND following PMDs, which is equivalent to a cohort study, and transitioned that design into a matched cohort study with onward follow-up to simulate a prospective study design and examine the risk of PMDs after PND (within the same study population). Incident PND and PMDs were identified through clinical diagnoses or prescribed medications. We randomly selected 10 pregnant women without PND, individually matched to each PND case on maternal age and calendar year using incidence density sampling (N: 84,949: 849,482). We (1) calculated odds ratio (OR) and 95% confidence intervals (CIs) of PMDs using conditional logistic regression in the nested case-control study. Demographic factors (country of birth, educational level, region of residency, and cohabitation status) were adjusted for. We (2) calculated the hazard ratio (HR) and 95% CIs of PMDs subsequent to PND using stratified Cox regression in the matched cohort study. Smoking, BMI, parity, and history of psychiatric disorders were further controlled for, in addition to demographic factors. Pregnancies from full sisters of PND cases were identified for sibling comparison, which contrasts the risk within each set of full sisters discordant on PND. In the nested case-control study, we identified 2,488 PMDs (2.9%) before pregnancy among women with PND and 5,199 (0.6%) among controls. PMDs were associated with a higher risk of subsequent PND (OR 4.76, 95% CI [4.52,5.01]; p < 0.001). In the matched cohort with a mean follow-up of 7.40 years, we identified 4,227 newly diagnosed PMDs among women with PND (incidence rate (IR) 7.6/1,000 person-years) and 21,326 among controls (IR 3.8). Compared to their matched controls, women with PND were at higher risk of subsequent PMDs (HR 1.81, 95% CI [1.74,1.88]; p < 0.001). The bidirectional association was noted for both prenatal and postnatal depression and was stronger among women without history of psychiatric disorders (p for interaction < 0.001). Sibling comparison showed somewhat attenuated, yet statistically significant, bidirectional associations. The main limitation of this study was that our findings, based on clinical diagnoses recorded in registers, may not generalize well to women with mild PMDs or PND.

CONCLUSIONS

In this study, we observed a bidirectional association between PMDs and PND. These findings suggest that a history of PMDs can inform PND susceptibility and vice versa and lend support to the shared etiology between both disorders.

The long-term course and prognosis of postpartum depression: a retrospective longitudinal cohort study

The purpose is to investigate the natural course and long-term prognosis of postpartum depression (PPD). In this retrospective longitudinal cohort study, mothers diagnosed as either suffering from PPD or without PPD were reassessed 5-8 years thereafter by a semi-structured interview and their charts were reviewed for past psychiatric illness prior to the index (initial) episode and for new-onset episodes in the following years. Present psychiatric state was also evaluated by interview and questionnaires. Sixty-five mothers with and 35 without past PPD underwent the full assessment. A total of 66.2% of mothers with past PPD had any axis I psychopathology before their index PPD episode, compared with only 8.6% in the non-PPD group (p < 0.001, φ = .55). Furthermore, 37.2% of the females who had a history of PPD and experienced subsequent childbirths during the follow-up years, developed at least one new episode of PPD. Throughout the 5 years subsequent to the index PPD episode, 42.5% of the PPD group compared with only 3.7% for the non-PPD group developed a new episode of depression (p < 0.001). Lastly, reported psychopathology was higher and functional level was significantly worse in the PPD group at the time of reassessment. Females who develop an episode of PPD show a high degree of subsequent psychopathology and unfavorable prognosis. Clinicians treating females for PPD should consider a longer treatment continuation phase in an effort to prevent further psychopathology and a closer follow-up program.

Turkish validity and reliability of the postpartum stressors scale

This study was conducted to examine the validity and reliability of the Postpartum Stressor Scale (PPSS) in Turkish.177 women were included in the methodological study. The data were collected between 24 September 2018 and 24 January 2019. The validity and validity of PPSS according to the language validity and expert opinions was provided by the translation-back translation method. It was determined that the Turkish form of the PPSS did not occur in three sub-dimensions such as the original structure. Therefore, the factor loadings of the PPSS one-dimensional scale ranged from 0.481 to 0.678, and the explained variance (35.3%) was sufficient. According to the results of CFA, factor loadings of the model ranged from 0.40 to 0.64, and t values of all substances were above 1.96. As a result of structural equation modeling. The obtained fit index values of the scale were found to be x2/SD 1.88, GFI 0.93, AGFI 0.88, CFI 0.95, RMSEA 0.071 and SRMR 0.065, and the model was acceptable. The Cronbach's alpha reliability coefficient of PPSS was 0.76. In all items of PPSS, item total score correlations were found to be over 0.30 and there was no need to exclude item from the scale. PPSS was determined as a reliable and valid tool for Turkish society. There was a positive significant correlation between PPSS and PSS (p = 0.000). When the mean scores of lower 27% and upper 27% were compared, statistically significant difference was found between the groups (p = 0.000). The mean score of PPSS was 16.67 ± 5.74. As a result of the study, it was determined that the Turkish version of PPSS was a valid and reliable measurement tool.

Postpartum Psychosis: A Review of Risk Factors, Clinical Picture, Management, Prevention, and Psychosocial Determinants

Postpartum psychosis is rare, but is a serious clinical and social problem. On its own, it is not included in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) or ICD-10 (International Statistical Classification of Diseases and Related Health Problems) as a disease entity, and current diagnostic criteria equate it with other psychoses. This poses a serious legal problem and makes it difficult to classify. The disorder is caused by a complex combination of biological, environmental, and cultural factors. The exact pathophysiological mechanisms of postpartum psychosis remain very poorly understood. There is a need for further research and increased knowledge of the medical sector in the prevention and early detection of psychosis to prevent stigmatization of female patients during a psychiatric episode. It is necessary to regulate its position in the DSM5 and ICD-10. Attention should be paid to the social education of expectant mothers and their families. This article aims to review the current status of risk factors, prevention, and management of postpartum psychosis.

"Echoes of a dark past" is a history of maternal childhood maltreatment a perinatal risk factor for pregnancy and postpartum trauma experiences? A longitudinal study

BACKGROUND

Although associations between maternal exposure to adverse childhood experiences (ACEs) and perinatal anxiety and depression are established, there is a paucity of information about the associations between ACEs and perinatal trauma and perinatal post-traumatic stress outcomes. For the purposes of this article, perinatal trauma is defined as a very frightening or distressing event that may result in psychological harm. The event must have been related to conception, pregnancy, birth, and up to 12 months postpartum.

METHODS

Women recruited at an antenatal appointment (n = 262) were invited to complete online surveys at two-time points; mid-pregnancy and eight weeks after the estimated date of delivery. The ACE Q 10-item self-reporting tool and a perinatal trauma screen related to the current and/or a previous perinatal period were completed. If the perinatal trauma screen was positive at either time point in the study, women were invited to complete a questionnaire examining symptoms of perinatal post-traumatic stress disorder and, if consenting, a clinical interview where the Post-traumatic Symptoms Scale was administered.

RESULTS

Sixty women (22.9%) reported four or more ACEs. These women were almost four times more likely to endorse perinatal trauma, when compared with those who either did not report ACEs (OR = 3.6, CI 95% 1.74 - 7.36, p < 0.001) or had less than four ACEs (OR = 3.9, CI 95% 2.037.55, p < 0.001). A 6-sevenfold increase in perinatal trauma was seen amongst women who reported having at least one ACE related to abuse (OR = 6.23, CI 95% 3.32-11.63, p < 0.001) or neglect (OR = 6.94, CI 95% 2.95-16.33, p < 0.001). The severity of perinatal-PTSD symptoms for those with perinatal trauma in pregnancy was significantly higher in those women exposed to at least one ACE related to abuse.

CONCLUSIONS

Awareness of maternal exposure to childhood adversity/maltreatment is critical to providing trauma-informed approaches in the perinatal setting. Our study suggests that routine screening for ACEs in pregnancy adds clinical value. This adds to previous research confirming the relationship between ACEs and mental health complexities and suggests that ACEs influence perinatal mental health outcomes.

Systematic review of the association between adverse life events and the onset and relapse of postpartum psychosis

Postpartum psychosis is defined as a psychotic episode occurring within 4 to 6  weeks of childbirth. While there is robust evidence that adverse life events are associated with the onset and relapse of psychosis outside the postpartum period, the extent to which these contribute to postpartum psychosis is less clear. This systematic review examined whether adverse life events are associated with an increased likelihood of developing postpartum psychosis or subsequent relapse in women diagnosed with postpartum psychosis. The following databases were searched from inception to June 2021: MEDLINE, EMBASE, PsycInfo. Study level data were extracted including setting, number of participants, type of adverse event, and differences between groups. A modified version of the Newcastle-Ottawa Quality Assessments Scale was used to assess risk of bias. In total, 1933 records were identified, of which 17 met the inclusion criteria, comprising nine case-control studies and eight cohort studies. Most studies (16/17) examined the association between adverse life events and the onset of postpartum psychosis, with only in which the outcome was relapse of psychosis. Overall, there were 63 different measures of adversity examined (most of which were examined in a single study only) and 87 associations between these measures and postpartum psychosis tested across the studies. In terms of statistically significant associations with onset/relapse of postpartum psychosis, 15 (17%) were positive (i.e., the adverse event increased the risk of onset/relapse), 4 (5%) were negative, and 68 (78%) were not statistically significant. Our review highlights the diversity of risk factors examined in this field, with few attempts at replication, hence limiting the ability to conclude that any single risk factor is robustly associated with the onset of postpartum psychosis. Further large-scale studies, that attempt to replicate earlier studies, are urgently needed to determine whether adverse life events play a role in the onset and exacerbation of postpartum psychosis.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=260592], identifier [CRD42021260592].

Is There an Inflammatory Profile of Perinatal Depression?

PURPOSE OF REVIEW

To synthesize and critically examine recent evidence regarding associations between immune system activity and perinatal depression.

RECENT FINDINGS

Despite a significant number of studies assessing potential immunological markers of perinatal depression, it does not appear that levels of any individual pro- or anti-inflammatory marker is a useful predictor of perinatal depression. Some recent studies have observed differences in overall immune system functioning and adaptation across this period, taking into account multiple pro- and anti- inflammatory markers. Furthermore, there is evidence for interactions between depression and maternal psychosocial factors. Immune system functioning may be a mechanism through which social determinants of health contribute to risk for perinatal depression. There is substantial evidence implicating dysregulated immune activity in perinatal depression, yet little clarity regarding a consistent immune profile, especially based on analysis of circulating peripheral cytokines.

Self-esteem, adverse life events, and mental health diagnoses among Black women living with HIV

PURPOSE

Black women in the U.S. are disproportionately impacted by HIV and adverse life events (ALE). High self-esteem has been noted as a protective factor and low self-esteem has been linked to mental health diagnoses. However, the existing literature is limited in the examination of how self-esteem may buffer relationships between ALE and mental health diagnoses among Black women living with HIV (BWLWH).

METHODS

One hundred and nineteen BWLWH completed self-report measures on self-esteem (Rosenberg Self-Esteem Scale) and ALE (Life Events Checklist for DSM-5) (e.g. sexual assault, physical assault, accidents, natural disaster) as well as a clinical interview (via Mini-International Neuropsychiatric Inventory) to diagnose current depression, PTSD, and suicidality.

RESULTS

Multivariable logistic regressions indicated that higher self-esteem was associated with lower likelihood of current depression (OR = .894, p < .01), PTSD (OR = .838, p < .001) and suicidality (OR = .889, p < .05). Interactions between self-esteem and total ALE significantly predicted current depression (OR = .000003, p < .05) and PTSD (OR = 2.7182 × 10-9, p < .001); and higher total ALE related to higher likelihood of current PTSD only among BWLWH reporting lower self-esteem (OR = 1.21, p < .05).

CONCLUSION

Interventions addressing mental health diagnoses among BWLWH should incorporate strategies to enhance self-esteem.

Postpartum depression: a developed and validated model predicting individual risk in new mothers

Postpartum depression (PPD) is a serious condition associated with potentially tragic outcomes, and in an ideal world PPDs should be prevented. Risk prediction models have been developed in psychiatry estimating an individual's probability of developing a specific condition, and recently a few models have also emerged within the field of PPD research, although none are implemented in clinical care. For the present study we aimed to develop and validate a prediction model to assess individualized risk of PPD and provide a tentative template for individualized risk calculation offering opportunities for additional external validation of this tool. Danish population registers served as our data sources and PPD was defined as recorded contact to a psychiatric treatment facility (ICD-10 code DF32-33) or redeemed antidepressant prescriptions (ATC code N06A), resulting in a sample of 6,402 PPD cases (development sample) and 2,379 (validation sample). Candidate predictors covered background information including cohabitating status, age, education, and previous psychiatric episodes in index mother (Core model), additional variables related to pregnancy and childbirth (Extended model), and further health information about the mother and her family (Extended+ model). Results indicated our recalibrated Extended model with 14 variables achieved highest performance with satisfying calibration and discrimination. Previous psychiatric history, maternal age, low education, and hyperemesis gravidarum were the most important predictors. Moving forward, external validation of the model represents the next step, while considering who will benefit from preventive PPD interventions, as well as considering potential consequences from false positive and negative test results, defined through different threshold values.

Childbirth Pain, Labor Epidural Analgesia, and Postpartum Depression: Recent Evidence and Future Directions

Pregnancy and childbirth are major life events for women and their families, characterized by physical, psychological, and emotional changes that can trigger anxiety, depression, and mental disorders in susceptible individuals. Acute labor pain is an independent risk factor for persistent pain in the postpartum period and is associated with depressive disorders. Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in pain management during labor. Although the relationships between labor pain, labor epidural analgesia, and postpartum depression have been studied by many investigators, the results of these studies are conflicting. Some literature suggest that labor epidural analgesia is associated with a reduction in the incidence of postpartum depression; however, other studies have failed to demonstrate this association. Unmet analgesic needs expectations, unmet birth expectations, and/or the quality of social support during labor may contribute to postpartum depression. The limitations of the published studies included differential misclassification of study variables and residual confounding, variations in the diagnosis of depression, and incomplete history data. Thus, future studies should include information on sociodemographic and patient-level variables and assessments of pain during labor or in the postpartum period. Better management of labor pain should be provided to prevent long-term morbidity and improve maternal and neonatal outcomes. Anesthesiologists could collaboratively work with obstetricians and perinatal psychiatrists to ensure that hospitals prioritize screening and treatment for postpartum depression.

Pregnant women with bipolar disorder who have a history of childhood maltreatment: Intergenerational effects of trauma on fetal neurodevelopment and birth outcomes

OBJECTIVES

Intergenerational transmission of trauma occurs when the effects of childhood maltreatment (CM) influence the next generation's development and health; prenatal programming via maternal mood symptoms is a potential pathway. CM is a risk factor for bipolar disorder which is present in 1.8% of pregnant women. Mood symptoms are likely to increase during pregnancy, particularly for those with a history of CM. We examined whether there was evidence for intergenerational transmission of trauma in utero in this population, and whether maternal mood was a transmission pathway.

METHODS

CM and maternal mood were self-reported by N = 82 pregnant women in treatment for bipolar disorder. Fetal heart rate variability (FHRV) was measured at 24, 30, and 36 weeks' gestation. Gestational age at birth and birth weight were obtained from medical charts.

RESULTS

A cluster analysis yielded two groups, Symptom+ (18.29%) and Euthymic (81.71%), who differed on severe mood symptoms (p < 0.001) but not on medication use. The Symptom+ group had more CM exposures (p < 0.001), a trend of lower FHRV (p = 0.077), and greater birth complications (33.3% vs. 6.07% born preterm p < 0.01). Maternal prenatal mood mediated the association between maternal CM and birth weight in both sexes and at trend level for gestational age at birth in females.

CONCLUSIONS

This is the first study to identify intergenerational effects of maternal CM prior to postnatal influences in a sample of pregnant women with bipolar disorder. These findings underscore the potential enduring impact of CM for women with severe psychiatric illness and their children.

Effect of Cytomegalovirus on the Immune System: Implications for Aging and Mental Health

Human cytomegalovirus (HCMV) is a major modulator of the immune system leading to long-term changes in T-lymphocytes, macrophages, and natural killer (NK) cells among others. Perhaps because of this immunomodulatory capacity, HCMV infection has been linked with a host of deleterious effects including accelerated immune aging (premature mortality, increased expression of immunosenescence-linked markers, telomere shortening, speeding-up of epigenetic "clocks"), decreased vaccine immunogenicity, and greater vulnerability to infectious diseases (e.g., tuberculosis) or infectious disease-associated pathology (e.g., HIV). Perhaps not surprisingly given the long co-evolution between HCMV and humans, the virus has also been associated with beneficial effects, such as increased vaccine responsiveness, heterologous protection against infections, and protection against relapse in the context of leukemia. Here, we provide an overview of this literature. Ultimately, we focus on one other deleterious effect of HCMV, namely the emerging literature suggesting that HCMV plays a pathophysiological role in psychiatric illness, particularly depression and schizophrenia. We discuss this literature through the lens of psychological stress and inflammation, two well-established risk factors for psychiatric illness that are also known to predispose to reactivation of HCMV.

The Impact of COVID-19 on Anxious and Depressive Symptomatology in the Postpartum Period

Background: Women in the postpartum period may be particularly vulnerable to the psychological effects of the COVID-19 pandemic. The aim of our study was to evaluate the impact of the coronavirus pandemic on postpartum depression and anxiety levels and the role of the fear of COVID-19 in its development. Methods: Women who delivered at the Bissaya Barreto Maternity Hospital, between 16 March and 16 June 2020 (Group 1: Birth in COVID-19 period, n = 207), recruited in the postpartum period, filled in a set of self-reported validated questionnaires: Perinatal Depression Screening Scale, Perinatal Anxiety Screening Scale, Profile of Mood States, Perseverative Thinking Questionnaire, Dysfunctional Beliefs Towards Maternity Scale, and the Fear of COVID-19 Scale. Levels of depressive and anxious symptomatology, negative affect, negative repetitive thinking, and the dysfunctional beliefs towards motherhood of these women were compared with data from samples of previous studies that included women whose delivery had occurred at the same Maternity Hospital before the COVID-19 pandemic period (Group 2: Birth before the COVID-19 period, n = 212). Results: Based on the cutoff points of the screening scales, the prevalence of clinically relevant depressive and anxious symptoms in Group 1 was 40.1% and 36.2%, respectively. Women in Group 1 had significantly higher levels of anxious and depressive symptoms, negative affect, negative repetitive thinking, and dysfunctional beliefs towards motherhood than women in Group 2 (p < 0.05). Fear of COVID-19 in the postpartum period was a predictor of depressive (ß = 0.262) and anxious (ß = 0.371) symptoms, explaining 6.9% and 13.7% of their variability, respectively (p < 0.001). Conclusion: During the COVID-19 pandemic, women in the postpartum period present greater depressive and anxious symptomatology, as well as increased risk factors.

Maternal History of Adverse Experiences and Posttraumatic Stress Disorder Symptoms Impact Toddlers’ Early Socioemotional Wellbeing: The Benefits of Infant Mental Health-Home Visiting

Background

The present study examined the efficacy of the Michigan Model of Infant Mental Health-Home Visiting (IMH-HV) infant mental health treatment to promote the socioemotional wellbeing of infants and young children. Science illuminates the role of parental “co-regulation” of infant emotion as a pathway to young children’s capacity for self-regulation. The synchrony of parent–infant interaction begins to shape the infant’s own nascent regulatory capacities. Parents with a history of childhood adversity, such as maltreatment or witnessing family violence, and who struggle with symptoms of post-traumatic stress may have greater challenges in co-regulating their infant, thus increasing the risk of their children exhibiting social and emotional problems such as anxiety, aggression, and depression. Early intervention that targets the infant–parent relationship may help buffer the effect of parental risk on child outcomes.

Methods

Participants were 58 mother–infant/toddler dyads enrolled in a longitudinal randomized control trial testing the efficacy of the relationship-based IMH-HV treatment model. Families were eligible based on child age (&lt;24 months at enrollment) and endorsement of at least two of four socio-demographic factors commonly endorsed in community mental health settings: elevated depression symptoms, three or more Adverse Childhood Experiences (ACEs) parenting stress, and/or child behavior or development concerns. This study included dyads whose children were born at the time of study enrollment and completed 12-month post-baseline follow-up visits. Parents reported on their own history of ACEs and current posttraumatic stress disorder (PTSD) symptoms, as well as their toddler’s socioemotional development (e.g., empathy, prosocial skills, aggression, anxiety, prolonged tantrums).

Results

Maternal ACEs predicted more toddler emotional problems through their effect on maternal PTSD symptoms. Parents who received IMH-HV treatment reported more positive toddler socioemotional wellbeing at follow-up relative to the control condition. The most positive socioemotional outcomes were for toddlers of mothers with low to moderate PTSD symptoms who received IMH-HV treatment.

Conclusion

Results indicate the efficacy of IMH-HV services in promoting more optimal child socioemotional wellbeing even when mothers reported mild to moderate PTSD symptoms. Results also highlight the need to assess parental trauma when infants and young children present with socioemotional difficulties.

Adverse Childhood Experiences and Current Psychosocial Stressors: Exploring Effects on Mental Health and Parenting Outcomes from a Mother-Baby Partial Hospital Program

OBJECTIVES

Adverse childhood experiences (ACEs) can detrimentally impact perinatal mental health, birth outcomes, and parenting behaviors. Proximal psychosocial stressors also increase risks to perinatal health and wellbeing. Additional research on effective perinatal mental health programs is needed, especially for individuals and families with historical and concurrent adversity, and those with moderate to severe symptoms.

METHODS

The Mother-Baby Day Hospital at Hennepin County Medical Center provides trauma-informed, multi-generation treatment for perinatal women. Data were collected from patients between January 2016 and September 2019. Self-reported depression, anxiety, and maternal functioning assessments were administered pre- and post-treatment. Patients completed the ACE questionnaire and indicators of current psychosocial stressors (i.e., food insecurity, housing insecurity, and social support) at intake. A series of bivariate tests and hierarchical regression models examined relationships among variables, including whether distal and proximal adversity predicted post-treatment symptoms.

RESULTS

159 Perinatal patients consented to research and completed the ACEs questionnaire at first admission. High proportions of patients reported 4+  ACEs and current psychosocial stressors. Effect sizes for associations between ACEs, psychosocial stressors, and self-report symptoms were small to moderate. Individuals with food or housing insecurity entered treatment with higher anxiety. In regression models, the most robust predictors of post-treatment symptoms were pre-treatment symptoms. Effects of ACEs on post-treatment depression and food insecurity on post-treatment maternal functioning approached the adjusted significance cut-off (p < .01). CONCLUSIONS FOR PRACTICE: Current psychosocial stressors and ACEs did not substantially limit post-treatment depression, anxiety, and maternal functioning outcomes. High prevalence of ACEs and psychosocial stressors highlight the need for trauma-informed, multi-generation treatments to improve maternal mental health and parenting capacity.

Cumulative childhood trauma and complex psychiatric symptoms in pregnant women and expecting men

BACKGROUND

Women and men having been exposed to childhood trauma would be at high risk of various mental health symptoms while awaiting a child. This study aimed to evaluate the association between cumulative childhood trauma and the accumulation of symptoms belonging to different psychiatric problems in pregnant women and expecting men.

METHODS

We first examined prevalence rates of childhood trauma across our samples of 2853 pregnant women and 561 expecting men from the community. Second, we evaluated the association between cumulative childhood trauma and symptom complexity (i.e., the simultaneous presentation of symptoms belonging to multiple psychiatric problems) using subsamples of 1779 pregnant women and 118 expecting men. Participants completed self-reported measures of trauma (Childhood Trauma Questionnaire) and psychiatric symptoms (PTSD Checklist for DSM-5; Kessler Psychological Distress Scale; State-Trait Anger Expression Inventory-2; Self and Interpersonal Functioning Scale).

RESULTS

Trauma was more frequent in pregnant women than in expecting men and in participants reporting sociodemographic risk factors than in those not reporting any. A dose-response relationship was observed between the number of different traumas reported by pregnant women and expecting men and the complexity of their psychiatric symptoms, even when controlling for the variance explained by other risk factors. Women having been exposed to cumulative childhood trauma were 4.95 times more at risk of presenting comorbid psychiatric problems during pregnancy than non-exposed women.

CONCLUSIONS

Childhood trauma is frequent in the general population of pregnant women and expecting men and is associated with symptom complexity during the antenatal period. These findings call for delivering and evaluating innovative trauma-informed antenatal programs to support mental health and adaptation to parenthood in adults having been exposed to childhood trauma.

Scaling up Mental Healthcare for Perinatal Populations: Is Telemedicine the Answer?

PURPOSE OF REVIEW

Telemedicine has transformed our ability to access and offer mental healthcare. There remain key questions to facilitate scalable, patient-centered solutions for perinatal mental health. We critically evaluate the recent literature and propose potential future directions.

RECENT FINDINGS

The current literature highlights the promise of telemedicine in the prevention and treatment of perinatal depression, including the preference for and the potential efficacy of telemedicine-delivered mental healthcare when compared to in-person treatments. There remains a need for large, adequately powered randomized controlled trials; integration of trauma into depression and anxiety trials, transdiagnostic treatment of perinatal women, and scaling up these effective treatments into existing health and payer systems. Pragmatic, evidence-based solutions exist to effectively scale-up treatments for perinatal mental health. While research is underway to address the growing treatment gap, questions remain regarding who will deliver and pay for these treatments and how we can leverage telemedicine to treat perinatal mental health transdiagnostically.

Brief postpartum separation from offspring promotes resilience to lipopolysaccharide challenge-induced anxiety and depressive-like behaviors and inhibits neuroinflammation in C57BL/6J dams

Emerging evidence indicates an important role for neuroinflammation in depression. Brief maternal separation promotes resilience to depression in offspring, but relatively little is known about the effects of different durations of postpartum separation (PS) from offspring on anxiety and depressive-like behaviors in dams following immune challenge. Lactating C57BL/6J mice were subjected to no separation (NPS), brief PS (15 min/day, PS15) or prolonged PS (180 min/day, PS180) from postpartum day (PPD) 1 to PPD21 and then injected with lipopolysaccharide (LPS). Behavioral tests, including the open field test (OFT) and forced swimming test (FST), were carried out at 24 h after the injection. LPSresulted in anxiety and depressive-like behaviors in NPS dams and activated ionized calcium-binding adaptor molecule (Iba1), an important biomarker of microglia, in the hippocampus. However, compared with NPS + LPS dams, PS15 + LPS dams spent significantly more time in the center of the OFT (anxiety-like behavior) and exhibited lower immobility time in the FST (depressive-like behavior), which indicated a phenomenon of resilience. Furthermore, the activation of neuroinflammation was inhibited in PS15 dams. Specifically, levels of the Iba1 mRNA and protein were decreased, while the mRNA expression of NLR family pyrin domain containing 3 (NLRP3) inflammasome/interleukin-18 (IL-18)/nuclear factor kappa-B (NF-κB) was decreased in the hippocampus. Furthermore, positive linear correlations were observed between microglial activation and LPS-induced depressive-like behaviors in dams. Collectively, the findings of this study confirm that brief PS from offspring promotes resilience to LPS immune challenge-induced behavioral deficits and inhibits neuroinflammation in dams separated from their offspring during lactation.

The influence of family therapy on psychological stress and social adaptability of depressed patients

BACKGROUND

with the increase of study and life pressure, the number of depressed college students showed an increasing trend year by year, and the drug treatment alone could not achieve a comprehensive recovery of depression patients, so it was more necessary to pay attention to the spiritual treatment.

OBJECTIVE

this research aimed to better understand the relationship between college students' depression and life events, social support, psychological pressure, and coping style, and the influence of systematic family therapy on depression degree, psychological stress, and social adaptability of college students with depression.

METHODS

in this study, 105 college students with depression were selected as the research object, and healthy college students were taken as the control group. Through questionnaire, the differences in life events, social support, psychological stress, and coping styles between the groups were compared. The correlation between the degree of depression and various variables were analyzed, and the impact path of each variable on depression was analyzed using the path analysis model. Depression patients were then divided into a conventional group treating with conventional medications and an observation group treating with systematic family interventions. Differences in Hamilton Depression Scale-17, (HAMD-17), CPSS, and Social Adaptive Functioning Evaluation (SAFE) scores were compared and analyzed between the two groups before treatment (T1), during the treatment (T2), and after treatment(T3).

RESULTS

there were significant differences in scores of life events, social support, psychological stress, and coping styles between the healthy control group and the depressed patients (P < 0.05). There was an obvious correlation between different depression degrees and life events, social support, psychological stress, and coping styles (P < 0.05). Life events, social support, and psychological stress had a direct and significant impact on depression (0.250, 0.218, and 0.392; P < 0.05), and they also had an indirect and significant impact on depression through coping styles (P < 0.05). The systematic family treatment model could significantly reduce HAMD-17 and CPSS scores (P < 0.05), and significantly improve SAFE scores (P < 0.05).

CONCLUSIONS

adverse life events, lack of social support, excessive psychological stress, and negative coping styles can aggravate college students' depression. Systematic family therapy can improve the degree of depression, reduce the psychological stress, and enhance the social adaptability of college students with depression.

The impact of childhood trauma on psychological interventions for depression during pregnancy and postpartum: a systematic review

Women who have experienced childhood trauma (CT) are at increased risk for depression during pregnancy and postpartum, pregnancy complications, and adverse child outcomes. There are effective psychotherapeutic interventions to treat depression during pregnancy and postpartum, yet there is a paucity of literature on the impact of CT on treatment outcomes. This review aims to determine whether and how maternal CT history affects the outcomes of psychological interventions for depression during pregnancy and postpartum. PubMed, PsycINFO, and Cochrane Library searches were conducted to identify papers on psychological interventions designed to treat depression during pregnancy and postpartum in women with CT. Seven manuscripts, describing six studies, met the inclusion criteria (N = 1234). Three studies utilized core principles of interpersonal psychotherapy (IPT). Two studies investigated interventions based on cognitive behavioral therapy (CBT). One study was based on a psychoeducation component. Results suggest that IPT-based interventions are beneficial for women with CT. The evidence regarding CBT-based interventions is less conclusive. This review is written in light of the paucity of research addressing the question systematically. The Childhood Trauma Questionnaire (CTQ) was the main measure used to assess CT. Trauma related to accidents, illness, and political violence was not included. The results are only applicable to interventions based on either IPT or CBT and cannot be generalized to other forms of psychotherapy. Psychotherapeutic interventions are beneficial for depressed women with history of CT during pregnancy and postpartum; however, further systematic research is needed.

Heart rate variability in late pregnancy: exploration of distinctive patterns in relation to maternal mental health

Exploration of photoplethysmography (PPG), a technique that can be translated to the clinic, has the potential to assess the autonomic nervous system (ANS) through heart rate variable (HRV) in pregnant individuals. This novel study explores the complexity of mental health of individuals in a clinical sample responding to a task in late pregnancy; finding those with several types of past or current anxiety disorders, greater trait anxiety, or greater exposure to childhood traumatic events had significantly different HRV findings from the others in the cohort. Lower high frequency (HF), a measure of parasympathetic activity, was found for women who met the criteria for the history of obsessive-compulsive disorder (OCD) (p = 0.004) compared with women who did not meet the criteria for OCD, and for women exposed to greater than five childhood traumatic events (p = 0.006) compared with those exposed to four or less childhood traumatic events. Conversely higher low frequency (LF), a measure thought to be impacted by sympathetic system effects, and the LF/HF ratio was found for those meeting criteria for a panic disorder (p = 0.006), meeting criteria for social phobia (p = 0.002), had elevated trait anxiety (p = 0.006), or exposure to greater than five childhood traumatic events (p = 0.004). This study indicates further research is needed to understand the role of PPG and in assessing ANS functioning in late pregnancy. Study of the impact of lower parasympathetic functioning and higher sympathetic functioning separately and in conjunction at baseline and in relation to tasks during late pregnancy has the potential to identify individuals that require more support and direct intervention.

Early- and late-onset postpartum depression exhibit distinct associated factors: the IGEDEPP prospective cohort study

OBJECTIVE

To identify risk factors for early- and late-onset postpartum depression (PPD) among a wide range of variables, including sociodemographic characteristics, childhood trauma, stressful life events during pregnancy and history of personal and family psychiatric disorders, and to assess the contribution of each risk factor.

DESIGN

Nested case-control study in a prospective longitudinal cohort study.

SETTING

Eight maternity departments in the Paris metropolitan area, France.

SAMPLE

A cohort of 3310 women with deliveries between November 2011 and June 2016.

METHODS

Cases were women with early- or late-onset PPD. Controls were women without depression during pregnancy or the postpartum period. Logistic regression adjusted on sociodemographic variables was performed for each outcome and a multivariable model was proposed based on a stepwise selection procedure.

MAIN OUTCOME MEASURES

Early- and late-onset PPD assessed at 2 months and 1 year postpartum, respectively.

RESULTS

Stressful life events during pregnancy have a dose-response relationship with both early- and late-onset PPD.

CONCLUSIONS

Early- and late-onset PPD presented distinct patterns of determinants. These results have important consequences in terms of prevention and specific care.

TWEETABLE ABSTRACT

Early- and late-onset postpartum depression are associated with stressful life events and psychiatric history.

Association between delivering live-born twins and acute psychiatric illness within 1 year of delivery

BACKGROUND

Having twins is associated with more depressive symptoms than having singletons. However, the association between having twins and psychiatric morbidity requiring emergency department visit or inpatient hospitalization is less well known.

OBJECTIVE

This study aimed to determine whether women have higher risk of having a psychiatric diagnosis at an emergency department visit or inpatient admission in the year after having twins vs singletons.

STUDY DESIGN

This retrospective cohort study used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes within the Florida State Inpatient Database and State Emergency Department Database, which have an encrypted identifier allowing nearly all inpatient and emergency department encounters statewide to be linked to the medical record. The first delivery of Florida residents at the age of 13 to 55 years from 2005 to 2014 was included, regardless of parity; women with International Classification of Diseases, Ninth Revision, Clinical Modification coding for psychiatric illness or substance misuse during pregnancy or for stillbirth or higher-order gestations were excluded. The exposure was an International Classification of Diseases, Ninth Revision, Clinical Modification code during delivery hospitalization of live-born twins. The primary outcome was an International Classification of Diseases, Ninth Revision, Clinical Modification code during an emergency department encounter or inpatient admission within 1 year of delivery for a psychiatric morbidity composite (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was drug or alcohol use or dependence within 1 year of delivery. We compared outcomes after delivery of live-born twins with singletons using multivariable logistic regression adjusting for sociodemographic and medical factors. We tested for interactions between independent variables in the primary model and conducted sensitivity analyses stratifying women by insurance type and presence of severe intrapartum morbidity or medical comorbidities.

RESULTS

A total of 17,365 women who had live-born twins and 1,058,880 who had singletons were included. Within 1 year of birth, 1.6% of women delivering twins (n=270) and 1.6% of women delivering singletons (n=17,236) had an emergency department encounter or inpatient admission coded for psychiatric morbidity (adjusted odds ratio, 1.00; 95% confidence interval, 0.88-1.14). Coding for drug or alcohol use or dependence in an emergency department encounter or inpatient admission in the year after twin vs singleton delivery was also similar (n=96 [0.6%] vs n=6222 [0.6%]; adjusted odds ratio, 1.11; 95% confidence interval, 0.91-1.36). However, women with public health insurance were more likely to be coded for drug or alcohol use or dependence after twin than singleton delivery (n=75 [1.2%] vs n=4858 [1.0%]; adjusted odds ratio, 1.27; 95% confidence interval, 1.01-1.60). Women with ≥1 medical comorbidity, severe maternal morbidity, or low income also had an increased risk of psychiatric morbidity after twin delivery (comorbidities, n=7438 [42.8%]; adjusted odds ratio, 1.30; 95% confidence interval, 1.25-1.34; severe maternal morbidity, n=940 [5.4%]; adjusted odds ratio, 1.65; 95% confidence interval, 1.49-1.81; lowest income quartile, n=4409 [26.8%]; adjusted odds ratio, 1.31; 95% confidence interval, 1.23-1.40; second-lowest income quartile, n=4770 [29.0%]; adjusted odds ratio, 1.34; 95% confidence interval, 1.26-1.43).

CONCLUSION

Overall, diagnostic codes for psychiatric illness or substance misuse in emergency department visits or hospital admissions in the year after twin vs singleton delivery are similar. However, women with who are low income or have public health insurance, comorbidities, or severe maternal morbidity are at an increased risk of postpartum psychiatric morbidity after twin vs singleton delivery.

Maternal adverse childhood experiences and postpartum depressive symptoms in young, low-income women

OBJECTIVES

Exposure to adverse childhood experiences (ACEs), such as child maltreatment and family dysfunction, is highly prevalent. Previous research has shown an association between ACEs and adult depression. The aim of the current study was to expand the existing literature by testing the association between ACEs and postpartum depression (PPD) symptoms in an urban, ethnically diverse sample of women.

METHODS

Participants (N = 746; ages 18-47; mean age = 27.3) were recruited at a large, urban university medical center as part of the Longitudinal Infant and Family Environment (LIFE) study. The association between ACEs and PPD symptoms were tested via hierarchical linear regression models.

RESULTS

The majority of the participants (61%) reported experiencing at least one type of ACEs prior to age 18. ACEs were positively associated with PPD symptoms (β = .29, p < .001), controlling for maternal race/ethnicity, age, educational attainment, marital status, household income, and infant gender and birth order.

CONCLUSIONS

The results showed that exposure to ACEs was related to PPD symptoms among low-income women. Screenings for ACEs during prenatal checkups may help identify women at risk of depression and facilitate timely prevention and treatment efforts.

Social and Demographic Factors Associated with Postnatal Depression Symptoms among HIV-Positive Women in Primary Healthcare Facilities, South Africa

Background: Mothers living with HIV are at risk for mental health problems, which may have a negative impact on the management of their HIV condition and care of their children. Although South Africa has a high prevalence of HIV, there is a dearth of studies on sociodemographic predictors of postnatal depression (PND) among HIV-positive women in South Africa, even in KwaZulu Natal, a province with the highest prevalence of HIV in the country. Objective: The objective of the study was to determine sociodemographic factors associated with the prevalence of postnatal depression symptoms among a sample of HIV-positive women attending health services from primary healthcare facilities in Umhlathuze District, KwaZulu Natal. Methods: A quantitative cross-sectional survey was used to collect data from 386 HIV-positive women who had infants aged between 1 and 12 weeks. The Edinburgh Postnatal Depression Scale (EPNDS), to which sociodemographic questions were added, was used to collect data. Results: The prevalence of PND symptoms among this sample of 386 HIV-positive women was 42.5%. The age of the mothers ranged from 16 to 42 years, with a mean of 29 years. The majority of the mothers were single or never married (85.5%; n = 330), living in a rural setting (81.9%; n = 316%), with a household income of less than R 2000 (estimated 125 USD) per month (64.9%; n = 120). The government child support grant was the main source of income for most of the mothers (53%; n = 183). PND symptoms were significantly associated with the participant’s partner having other sexual partners (p-value < 0.001), adverse life events (p-value = 0.001), low monthly income (p-value = 0.015), and being financially dependent on others (p-value = 0.023). Conclusion: The prevalence of PND symptoms among the sample is high, with a number of social and demographic factors found to be significantly associated with PND. This requires the consideration of sociodemographic information in the overall management of both HIV and postnatal depression. Addressing the impact of these factors can positively influence the health outcomes of both the mother and the baby.

Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review

Postpartum psychoses are a severe form of postnatal mood disorders, affecting 1–2 in every 1000 deliveries. These episodes typically present as acute mania or depression with psychosis within the first few weeks of childbirth, which, as life-threatening psychiatric emergencies, can have a significant adverse impact on the mother, baby and wider family. The nosological status of postpartum psychosis remains contentious; however, evidence indicates most episodes to be manifestations of bipolar disorder and a vulnerability to a puerperal trigger. While childbirth appears to be a potent trigger of severe mood disorders, the precise mechanisms by which postpartum psychosis occurs are poorly understood. This review examines the current evidence with respect to potential aetiology and childbirth-related triggers of postpartum psychosis. Findings to date have implicated neurobiological factors, such as hormones, immunological dysregulation, circadian rhythm disruption and genetics, to be important in the pathogenesis of this disorder. Prediction models, informed by prospective cohort studies of high-risk women, are required to identify those at greatest risk of postpartum psychosis.

A Comprehensive Conceptual Framework to Guide Clinical Practice and Research About Mental Health During the Perinatal Period

Perinatal mood and anxiety disorders (PMADs) affect up to 20% of pregnant and postpartum women and can have negative sequelae for maternal-child health. Nurses with clinical and research roles are on the front line of efforts to assess for and assist with prevention and intervention with PMAD symptoms. Thus, they can play an essential role in enhancing the mental well-being of women in the perinatal period and maternal-child health outcomes. The aim of this article is to assist nurses in this work by outlining the Comprehensive Model of Mental Health during the Perinatal Period, a conceptual framework for considering clinical and research opportunities to enhance perinatal mental health. The framework uses key principles that recognize biopsychoneuroimmunologic mechanisms involved in mental health; the key role that the experience of matrescence ("becoming a mother") plays in mental health and maternal-child health; and the mother-infant dyad as the functional unit during the perinatal period. Examples are provided of how the key principles of this framework might be used to enhance research and clinical practice about PMADs and, ultimately, enhance maternal-child health outcomes.

Young women are the most vulnerable to postpartum mental illness: A retrospective cohort study in UK primary care

BACKGROUND

Whilst childbirth is a leading cause of mental illness in women, how it affects women at different ages is unknown.

AIMS

We examine whether the effect of childbirth on mental illness varies at different ages.

METHODS

From 2,657,751 women identified from a UK population-based primary care database, 355,864 postpartum periods, with no history of mental illness, were matched on year of birth and general practice to 1,420,350 non-postpartum periods. Cox regression models were used to compare incident mental illness between postpartum and non-postpartum periods. These were measured using hazard ratios (HR) and hazard ratios adjusted for parity and prior pregnancy loss (aHR).

RESULTS

Strong evidence is presented that the effect of livebirth on mental illness was age-dependant for depression (p <0·001), anxiety (p 0·048) and affective psychosis (p 0·031). In 15-19 year olds, depression was over seven times more likely to occur in postpartum periods than non-postpartum periods (aHR 7·09, 95%CI 6·65-7·56); twice the effect in women overall (aHR 3·24 95%CI 3·18-3·29). 15-19 year olds were 50% more likely to develop anxiety in postpartum periods than non-postpartum periods (aHR 1·52, 95%CI 1·38-1·67), with little effect in women overall (aHR 1·07 95%CI 1·04-1·10). Livebirth had over twice the effect on affective psychosis in women aged 15-24 (15-19 year olds: aHR 2·71 95%CI 1·23-5·97; 20-24 year olds: aHR 2·79 95%CI 1·68-4·63) compared to women overall (aHR 1·66, 95%CI 1·29-2·14).

CONCLUSIONS

Younger women are far more vulnerable to the effect of childbirth on their mental health, particularly depression and anxiety.

Adverse childhood experiences and postpartum depression in bipolar disorder

BACKGROUND

Women are particularly vulnerable to recurrence of bipolar disorder (BD) following childbirth. Risk of postpartum psychosis (PP) is especially high, but postpartum depression (PPD) is also common. Adverse childhood experiences (ACEs) have not been associated with PP, but have been associated with PPD in non-bipolar samples. The relationship between ACEs and PPD within BD remains to be investigated. Here, we examined this association in a large, well-defined sample of women with BD.

METHODS

Participants were 575 parous women with DSM-IV BD. Lifetime psychopathology, including perinatal, was assessed via semi-structured interview and case-notes. ACEs, assessed via self-report and case-notes, were compared between women with lifetime PPD (n = 368) and those without a lifetime history of perinatal mood episodes (n = 207).

RESULTS

In univariate analysis exposure to 3 or more ACEs, and to childhood abuse specifically, was significantly associated with PPD (p = 0.026 and 0.041 respectively), but this did not remain significant after adjusting for lifetime number of episodes of depression and parity. Post-hoc analysis revealed more frequent episodes of depression to be associated with both a history of 3 or more ACEs and of childhood abuse.

LIMITATIONS

Limited range of ACEs assessed and potential recall bias.

CONCLUSIONS

Increased frequency of ACEs and particularly childhood abuse was associated with more frequent lifetime episodes of depression, but not specifically episodes with postpartum onset. Understanding factors that mediate the pathway between ACEs and PPD in BD has implications for risk prediction of PPD.

Atypical antipsychotic drug modulates early life infection induced impairment of hypothalamic-pituitary-adrenal axis: An age related study in mice

Evidences from human and animal studies indicate that exposure to infection during early life act as a stressor to impair the hypothalamic-pituitary-adrenal (HPA) axis and may be one of the contributing factors of mental illness of later life. Several atypical antipsychotic drugs (AAPDs) proved to be effective in alleviating psychiatric illness through normalization of HPA axis. However, AAPD are least tried to evaluate their efficacy in modulation of HPA axis impaired under infection. The present study elucidated that the treatment with AAPD paliperidone (PAL: 0.025 mg/kg/bw and 0.05 mg/kg/bw) during periadolescence period (postnatal day 35- postnatal day 56) dose-dependently normalized the HPA axis of the female mice who were gestationally (gestational day 15 and 17) exposed to bacterial endotoxin lipopolysaccharide (LPS: 800 μg/kg/bw; intraperitoneally). The effectiveness of PAL treatment in counteracting the LPS induced hyperactivity of HPA axis was age-related, better observed at postnatal day 120 than at postnatal day 200. The PAL modulation of HPA axis reflected at different levels: inhibition of hypothalamic CRF expression and reduction in plasma levels of adrenocorticotropin and corticosterone. Histopathological alterations such as hypertrophy and/or hyperplasia in cortical zona fasciculata as well as medullary chromaffin cells of adrenal also normalized on PAL treatment. The comparatively long wash out period after drug treatment (postnatal day 57- postnatal day 200) along with age related hormonal imbalance could be correlated to less effectiveness of PAL on HPA axis at postnatal day 200. PAL modulation of HPA axis might be through maintenance of cytokines and reproductive axis homeostasis.

Neurobiology of maternal mental illness

This chapter provides an overview of current research discoveries beginning to uncover the neurobiology of maternal mental illness. Results are described according to standard diagnostic categories (specifically, perinatal depression, perinatal anxiety and OCD, postpartum psychosis and bipolar disorder, and trauma and posttraumatic stress disorder), yet we aim to put this approach in context with the introduction of a classification model for psychiatric research, the research domain criteria, gaining traction in basic and clinical translational fields. We first review a new area of study, the neuroplasticity of the pregnant and postpartum brain, as work here has relevance for understanding the pathophysiology of mental disorders and may provide clues to changes in brain functioning that are related to compromised parenting in the context of postpartum depression. We next provide background information on neuroendocrine and immune changes during pregnancy and, to a lesser extent, the postpartum period, as alterations in these systems are significantly implicated in underlying neurobiology of mental illness for peripartum women. Our discussion of the major mental illnesses for pregnant and postpartum women includes neuroendocrine changes, neuroinflammation, and neurotransmitter alterations, as well as circuit dysfunction. Overall, remarkable progress has been made in identifying variations in neurobiology (and related systems) involved in maternal mental illness; yet, it is clear that, as classified with standard diagnostic systems, these are heterogeneous disorders and there is individual variability in the alterations in neurobiology for the same illness.

Association between stillbirth ≥23 weeks gestation and acute psychiatric illness within 1 year of delivery

BACKGROUND

Stillbirth has been associated with emotional and psychologic symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known.

OBJECTIVE

The purpose of this study was to determine whether women have a higher risk of experiencing clinician-diagnosed psychiatric morbidity in the year after stillbirth vs livebirth.

STUDY DESIGN

This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department databases. The first delivery of female Florida residents aged 13-54 years old from 2005-2014 was included; women with International Classification of Diseases, 9th Revision, Clinical Modification coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during delivery hospitalization of a stillbirth at ≥23 weeks gestation. The primary outcome was a primary or secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during an Emergency Department encounter or inpatient admission within 1 year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite of drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth vs livebirth using multivariable logistic regression, adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model.

RESULTS

A total of 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within 1 year of hospital discharge after stillbirth, 4.0% of the women (n=331) had an Emergency Department encounter or inpatient admission that was coded for psychiatric morbidity; the risk was nearly 2.5 times higher compared with livebirth (1.6%; n=19,746); adjusted odds ratio, 2.47; 95% confidence interval, 2.20- 2.77). Women also had higher risk of having an Emergency Department encounter or inpatient admission coded for drug or alcohol use or dependence in the year after delivery of stillbirth vs livebirth (124 [1.5%] vs 7033 [0.6%]; adjusted odds ratio, 2.41; 95% confidence interval, 1.99-2.90). Cox proportional hazard modeling suggested that the highest risk interval for postpartum psychiatric illness was within 4 months of stillbirth delivery (adjusted hazard ratio, 3.26; 95% confidence interval, 2.63-4.04), although the risk remained high during the 4-12 months after delivery (adjusted hazard ratio, 2.42; 95% confidence interval, 2.13-2.76).

CONCLUSION

Coding for psychiatric illness or substance misuse in Emergency Department visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly 2 per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until 4 months after delivery.

Allopregnanolone-based treatments for postpartum depression: Why/how do they work?

Recent FDA approval of an allopregnanolone-based treatment specifically for postpartum depression, brexanolone, now commercially called Zulresso®, is an exciting development for patients and families impacted by postpartum depression and allows us to start asking questions about why and how this compound is so effective. Allopregnanolone is a neuroactive steroid, or neurosteroid, which can be synthesized from steroid hormone precursors, such as progesterone, or synthesized de novo from cholesterol. Neurosteroids are positive allosteric modulators at GABA_A receptors (GABA_ARs), a property which is thought to mediate the therapeutic effects of these compounds. However, the durability of effect of brexanolone in clinical trials questions the mechanism of action mediating the remarkable antidepressant effects, leading us to ask why and how does this drug work. Asking why this drug is effective may provide insight into the underlying neurobiology of postpartum depression. Exploring how this drug works will potentially elucidate a novel antidepressant mechanism of action and may provide useful information for next generation drug development. In this review, we examine the clinical and preclinical evidence supporting a role for allopregnanolone in the underlying neurobiology of postpartum depression as well as foundational evidence supporting the therapeutic effects of allopregnanolone for treatment of postpartum depression.

Association Between Severe Maternal Morbidity and Psychiatric Illness Within 1 Year of Hospital Discharge After Delivery

OBJECTIVE

To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge.

METHODS

This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome.

RESULTS

A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58-1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05-3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64-2.23]).

CONCLUSION

Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.

Childhood adversity and sleep are associated with symptom severity in perinatal women presenting for psychiatric care

This study leverages psychiatric intake data from treatment-seeking perinatal women aiming to explore the understudied associations between childhood adversity, sleep quality, and severity of perinatal mental illness in this population. The sample is 578 perinatal women presenting for initial evaluation to a university-based perinatal psychiatry clinic. At intake, we collected demographics, adverse childhood experiences (ACEs), sleep quality, and diagnosis and symptom severity of depression, anxiety, and posttraumatic stress disorder (PTSD). Clinician-rated diagnoses showed that 65% of women met criteria for major depression, 23% for generalized anxiety disorder and 4% for PTSD; almost 30% of women had childhood adversity and 98.2% reported poor perinatal sleep quality. Regression analyses revealed differential associations between ACEs and sleep quality and perinatal mood symptoms; ACEs were significantly associated with pregnancy and postpartum PTSD, whereas sleep quality was associated with perinatal depression and generalized anxiety. Screening for ACEs and sleep quality during perinatal intake has high clinical utility, as these two factors significantly contribute to symptom severity across peripartum.

Maternal bereavement shortly before or during pregnancy and risk of postpartum psychotic illness: a population-based study from Denmark and Sweden

Purpose: Postpartum psychosis is a rare but severe complication following childbirth, with unknown etiology. This study investigated whether the death of a close family member — a source of severe stress — the year before or during pregnancy was associated with an increased risk of psychotic illness in the postpartum period among women without and with a history of psychiatric disorder.

Methods: We studied live births in Denmark during 1978–2008 and births in Sweden during 1973–2006 (n=5,246,978). Information on death of women’s relatives and partners and sociodemographic, health-, and pregnancy-related factors was obtained through linkage with nationwide registries.

Results: The death of a close relative the year before or during pregnancy was not associated with psychotic illness during the first 90 days postpartum among women without (adjusted HR 1.02, 95% CI 0.76–1.37) or with a history of psychiatric disorder (HR 0.96, 95% CI 0.74–1.25). Similarly, there was no association between bereavement and risk of postpartum psychosis according to the timing of the loss (the year before or during pregnancy), the relative’s cause of death (natural or unnatural), or the woman’s relationship to the deceased (parent/sibling or partner/older child).

Conclusions: Death of a close relative, one of the most severe sources of stress, before or during pregnancy was not associated with postpartum psychosis. Therefore, these data do not support the hypothesis that severely stressful life events, such as bereavement around the time of pregnancy, are associated with postpartum psychosis.

Toward a framework for best practices and research guidelines for perinatal depression research

This review article highlights the current state of perinatal depression (PND) research including established standards of care and innovative research in progress. PND can have a significant adverse impact on mother, child, and family; however, to date, wide-scale identification, prevention, and treatment have been limited. PND is heterogenous in presentation with likely multifactorial etiologies for each woman. Challenges in PND research are discussed including a need for universal tools, standardized measures, benchmarks, and best practices. Current examples are reviewed that highlight approaches to novel treatment paradigms and interventions. This includes reviewing epidemiologic studies in PND research, examining the biological underpinnings of PND, and discussing examples from this field and other fields currently developing translational research that spans from bench to bedside. Current and future challenges and opportunities in developing best practices for the treatment of PND are outlined. We also discuss the use of the NIMH Research Domain Criteria approach for PND research and provide recommendations for future directions in PND research collaboration. In conclusion, greater precision in perinatal psychiatry can be possible in the future with the development of guidelines and best practices that build on current work and apply innovative and collaborative approaches of scientists, providers, patients, community members, and government officials.

Neuroactive Steroids and GABAergic Involvement in the Neuroendocrine Dysfunction Associated With Major Depressive Disorder and Postpartum Depression

Stress and previous adverse life events are well-established risk factors for depression. Further, neuroendocrine disruptions are associated with both major depressive disorder (MDD) and postpartum depression (PPD). However, the mechanisms whereby stress contributes to the underlying neurobiology of depression remains poorly understood. The hypothalamic-pituitary-adrenal (HPA) axis, which mediates the body's neuroendocrine response to stress, is tightly controlled by GABAergic signaling and there is accumulating evidence that GABAergic dysfunction contributes to the impact of stress on depression. GABAergic signaling plays a critical role in the neurobiological effects of stress, not only by tightly controlling the activity of the HPA axis, but also mediating stress effects in stress-related brain regions. Deficits in neuroactive steroids and neurosteroids, some of which are positive allosteric modulators of GABA_A receptors (GABA_ARs), such as allopregnanolone and THDOC, have also been implicated in MDD and PPD, further supporting a role for GABAergic signaling in depression. Alterations in neurosteroid levels and GABAergic signaling are implicated as potential contributing factors to neuroendocrine dysfunction and vulnerability to MDD and PPD. Further, potential novel treatment strategies targeting these proposed underlying neurobiological mechanisms are discussed. The evidence summarized in the current review supports the notion that MDD and PPD are stress-related psychiatric disorders involving neurosteroids and GABAergic dysfunction.

Identification and Treatment of Peripartum Anxiety Disorders

Anxiety disorders in the peripartum period are common and frequently overlooked. They can present de novo or as exacerbations of generalized anxiety disorder, obsessive compulsive disorder, panic disorder and social anxiety disorder, or posttraumatic stress disorder. Calculating a score on the Edinburgh postnatal depression scale is a useful method of screening for these disorders while also screening for perinatal depression. Treatment includes psychotherapy, specifically cognitive behavioral therapy, and antidepressants, the choice of which should be balanced between the severity of symptoms and impact of functioning, risks of untreated illness, and the risks associated with the use of medications in pregnancy and lactation. In summary, anxiety disorders in the peripartum period should be recognized and treated promptly.

Pathophysiological mechanisms implicated in postpartum depression

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