A lifespan perspective on depression in the postpartum period in a racially and socioeconomically diverse sample of young mothers

BACKGROUND

Consistent evidence from retrospective reports and case registry studies indicates that a history of depression is a major risk factor for depression in the peripartum period. However, longitudinal studies with racially and socioeconomically diverse samples of young mothers are lacking, and little is known about developmental patterns of depression across the lifespan that can inform preventive interventions.

METHODS

Young primiparous mothers (n = 399, 13-25 years, 81% Black) were recruited from a population-based prospective study that began in childhood. Women reported on depression symptoms for at least 3 years prior to their pregnancy, during pregnancy, and at 4 months postpartum. Linear regression models were used to estimate change in pre-pregnancy depression severity and to evaluate associations between patterns of lifetime history and postpartum depression symptoms.

RESULTS

Results revealed high levels of continuity in depression from pregnancy to postpartum, and across multiple years pre-pregnancy to postpartum. Overall, depression severity leading up to pregnancy decreased over time, but patterns of worsening or improving symptoms were not associated with depression severity in the postpartum period. Instead, area under the pre-pregnancy trajectory curve, representing cumulative lifetime depression burden, was uniquely associated with postpartum depression after adjusting for prenatal depression severity.

CONCLUSIONS

Depression in the postpartum period should be considered within a lifespan perspective of risk that accumulates before conception. Clinical screening and early interventions are needed in adolescence and young adulthood to prevent the onset and persistence of depressive symptoms that could have long-term implications for peripartum health.

Using natural language from a smartphone pregnancy app to identify maternal depression

Depression is highly prevalent in pregnancy, yet it often goes undiagnosed and untreated. Language can be an indicator of psychological well-being. This longitudinal, observational cohort study of 1,274 pregnancies examined written language shared in a prenatal smartphone app. Natural language feature of text entered in the app (e.g. in a journaling feature) throughout the course of participants' pregnancies were used to model subsequent depression symptoms. Language features were predictive of incident depression symptoms in a 30-day window (AUROC = 0.72) and offer insights into topics most salient in the writing of individuals experiencing those symptoms. When natural language inputs were combined with self-reported current mood, a stronger predictive model was produced (AUROC = 0.84). Pregnancy apps are a promising way to illuminate experiences contributing to depression symptoms. Even sparse language and simple patient-reports collected directly from these tools may support earlier, more nuanced depression symptom identification.

Benzodiazepine withdrawal in pregnant women with opioid use disorders: An observational study of current clinical practices at a tertiary obstetrical hospital

BACKGROUND

As more patients are admitted for medical complications related to opioid use disorders, physicians are called upon to manage withdrawal from co-occurring substance use disorders. We present an observational study of pregnant women with comorbid opioid and sedative-hypnotic use disorders hospitalized for benzodiazepine withdrawal.

OBJECTIVES

Our primary aims were to assess current practices in withdrawal management in the perinatal period in patients admitted to an antepartum unit at a tertiary care setting with comorbid opioid and sedative-hypnotic use disorders; specifically, to identify patterns of withdrawal management, including the type of withdrawal protocol utilized, the total dosage of benzodiazepine used during that protocol, to assess patient variables associated with higher dosing, and to analyze neonatal outcomes.

METHODS

A chart review of psychiatry consultations for benzodiazepine withdrawal in antepartum women was conducted for patients seen over a 3 year period with manual extraction of patient age, number of pregnancies, modality of benzodiazepine withdrawal management (symptom-triggered versus standing benzodiazepine taper), total amount of benzodiazepine used during the detoxification period, active methadone conversion versus stable methadone dose on admission, and average fetal heart tones during the withdrawal detoxification period.

RESULTS

The majority of patients (83%) were undergoing methadone conversion or were stable on methadone maintenance. The mean cumulative benzodiazepine dose used was 8.3 ± 10.5 mg in lorazepam equivalents. Women placed on a symptom-triggered protocol received lower mean benzodiazepine doses (2.4 ± 6.9 mg) compared to those on a benzodiazepine taper in conjunction with a symptom-triggered protocol (17.9 ± 20.6 mg; p < 0.001). Women who started methadone during admission tended to receive lower mean lorazepam doses (7.1 ± 10.4) compared to women admitted on stable outpatient doses of methadone (11.5 ± 10.6; p = 0.07). Using t-test and chi-square analyses on a subgroup of women (N = 50), no differences were found between women placed on a taper compared to a symptom-triggered scale alone in neonatal outcomes such as APGARS, NICU admissions, and preterm delivery with low rates of complications in both groups.

CONCLUSIONS

A symptom-triggered benzodiazepine withdrawal protocol was associated with significantly lower total benzodiazepine use compared to standing taper regimens. Women started on methadone during admission tended to receive lower lorazepam doses compared to women admitted on stable doses of methadone. Preliminary maternal/neonatal outcomes were similar between symptom-triggered and taper groups.

Ovarian hormone fluctuation, neurosteroids, and HPA axis dysregulation in perimenopausal depression: a novel heuristic model

OBJECTIVE

In this conceptual review, the authors propose a novel mechanistic candidate in the etiology of depression with onset in the menopause transition ("perimenopausal depression") involving alterations in stress-responsive pathways, induced by ovarian hormone fluctuation.

METHOD

The relevant literature in perimenopausal depression, including prevalence, predictors, and treatment with estrogen therapy, was reviewed. Subsequently, the growing evidence from animal models and clinical research in other reproductive mood disorders was synthesized to describe a heuristic model of perimenopausal depression development.

RESULTS

The rate of major depressive disorder and clinically meaningful elevations in depressive symptoms increases two- to threefold during the menopause transition. While the mechanisms by which ovarian hormone fluctuation might impact mood are poorly understood, growing evidence from basic and clinical research suggests that fluctuations in ovarian hormones and derived neurosteroids result in alterations in regulation of the HPA axis by γ-aminobutyric acid (GABA). The authors' heuristic model suggests that for some women, failure of the GABAA receptor to regulate overall GABA-ergic tone in the face of shifting levels of these neurosteroids may induce HPA axis dysfunction, thereby increasing sensitivity to stress and generating greater vulnerability to depression.

CONCLUSIONS

The proposed model provides a basis for understanding the mechanisms by which the changing hormonal environment of the menopause transition may interact with the psychosocial environment of midlife to contribute to perimenopausal depression risk. Future research investigating this model may inform the development of novel pharmacological treatments for perimenopausal depression and related disorders, such as postpartum depression and premenstrual dysphoric disorder.

Are maternal depression or symptom severity associated with breastfeeding intention or outcomes?

OBJECTIVE

Breastfeeding confers many health benefits to mothers and infants, while depression negatively affects mothers and infants. The aims of this study were to determine relationships between (1) major depressive disorder (MDD) and depressive symptom severity during pregnancy and breastfeeding intention; (2) MDD and depressive symptom severity during pregnancy and breastfeeding initiation and status at 2 and 12 weeks; and (3) serotonin reuptake inhibitor (SRI) use and breastfeeding intention, initiation, and status at 2 and 12 weeks.

METHOD

Women were followed prospectively from pregnancy through 12 weeks postpartum for infant feeding intention (breast, breast and formula, formula, and uncertain), feeding practices and MDD (Structured Clinical Interview for DSM-IV Disorders), and depressive symptom severity (Hamilton Depression Rating Scale). Bivariate analyses and multivariable regression modeling were conducted. The study was conducted from July 2004 to September 2007.

RESULTS

Study participants (intention n = 168, initiation n = 151, 2 weeks n = 137, 12 weeks n=103) were well educated (63% college degrees), older (49% ≥ or = 31 years), and predominantly white (77%). At enrollment, 23% had MDD, 21% had significant depressive symptoms, and 16% were taking an SRI. Neither MDD nor depressive symptom severity in pregnancy was related to breastfeeding intention, initiation or duration at 2 and 12 weeks. Intention to exclusively breastfeed was the most significant predictor of breastfeeding initiation and duration. SRI use in pregnancy was negatively associated with breastfeeding intention. SRI use at 2 weeks was negatively associated with 12-week breastfeeding status.

CONCLUSION

Pregnancy is the optimal time to intervene to increase breastfeeding rates. Future research should identify strategies to overcome breastfeeding barriers posed by SRI use.

Prepregnancy body mass index, gestational weight gain, and the likelihood of major depressive disorder during pregnancy

OBJECTIVE

We assessed the relation between prepregnancy body mass index (BMI) and the likelihood of major depressive disorder (MDD) during pregnancy and tested whether this association was modified by gestational weight gain.

METHOD

Women (N = 242) were enrolled at < 20 weeks gestation into a prospective cohort study. Diagnosis of MDD was made with the Structured Clinical Interview for DSM-IV at 20, 30, and 36 weeks gestation. Gestational weight gain was compared with the 1990 Institute of Medicine weight gain recommendations. To assess the independent association between prepregnancy BMI and the odds of MDD, MDD at each time point was used as the dependent measure in a multivariable longitudinal logistic regression model employing generalized estimating equations. The data were collected from 2003-2007.

RESULTS

There was a strong, positive dose-response association between prepregnancy BMI and the likelihood of MDD (P = .002). Compared with a BMI of 18, the adjusted odds ratios (95% confidence interval) for BMIs of 23, 28, and 33 were 1.4 (1.1 to 1.7), 1.9 (1.3 to 2.9), and 2.6 (1.4 to 4.3), respectively. Gestational weight gain significantly modified this effect. Among women with weight gains within and above the 1990 Institute of Medicine recommendations, pregravid overweight was associated with a greater likelihood of MDD. In contrast, all women with weight gains below recommended levels had an elevated odds of depression regardless of their pregravid BMI (P < .05).

CONCLUSIONS

Because pregravid overweight, poor gestational weight gain, and MDD all pose substantial risks for fetal development and birth outcomes, health care providers should monitor depression levels in these women to facilitate appropriate depression intervention.

Serotonin 1A receptor binding and treatment response in late-life depression

Depression in late life carries an increased risk of dementia and brittle response to treatment. There is growing evidence to support a key role of the serotonin type 1A (5-HT(1A)) receptor as a regulator of treatment response, particularly the 5-HT(1A) autoreceptor in the dorsal raphe nucleus (DRN). We used [11C]WAY 100635 and positron emission tomography (PET) to test our hypothesis that 5-HT(1A) receptor binding in the DRN and prefrontal cortex is altered in elderly depressives and that these measures relate to treatment responsivity. We studied 17 elderly subjects with untreated (nonpsychotic, nonbipolar) major depression (four men, 13 women; mean age: 71.4+/-5.9) and 17 healthy control subjects (eight men, nine women; mean age: 70.0+/-6.7). Patients were subsequently treated with paroxetine as part of a clinical trial of maintenance therapies in geriatric depression. [11C]WAY 100635 PET imaging was acquired and binding potential (BP) values derived using compartmental modeling. We observed significantly diminished [11C]WAY 100635 binding in the DRN in depressed (BP = 2.31+/-0.90) relative to control (BP = 3.69+/-1.56) subjects (p = 0.0016). Further, the DRN BP was correlated with pretreatment Hamilton Depression Rating Scores (r = 0.60, p = 0.014) in the depressed cohort. A trend level correlation between DRN binding and time to remission (r = 0.52, p = 0.067) was observed in the 14 depressed patients for whom these data were available. Our finding of decreased [11C]WAY 100635 binding in the brainstem region of the DRN in elderly depressed patients supports evidence of altered 5-HT(1A) autoreceptor function in depression. Further, this work indicates that dysfunction in autoreceptor activity may play a central role in the mechanisms underlying treatment response to selective serotonin reuptake inhibitors in late-life depression.

Positron emission tomography imaging of the aging brain

PET imaging provides a vital means to study the human brain in vivo in aging and early disease states. PET studies using selective markers for brain metabolism and neurotransmitter function have uncovered a wealth of information on healthy and pathologic brain aging, and its relationship to behavior and mood states. Recognition of inherent potential confounds in the use of PET in aging studies is essential to the proper interpretation of these data.