The lifetime costs of perinatal depression and anxiety in Brazil

BACKGROUND

Each year, an estimated 860,000 Brazilian women experience depression and anxiety perinatally. Despite well-known devastating impacts of these conditions on mothers and children, they remain neglected in low- and middle-income countries. Knowing the costs of untreated perinatal depression and anxiety can inform decision-making.

METHODS

Simulation modelling is used to examine lifetime costs of perinatal depression and anxiety for a hypothetical cohort of women and their children, followed until children are aged 40 years. Costs are measured from a societal perspective, including healthcare expenditure, productivity and health-related quality of life losses; 2017 data are taken from country-specific sources. Present values are calculated using a discount rate of 3 %.

RESULTS

Lifetime cost of perinatal depression and anxiety in Brazil are USD 4.86 billion or R$ 26.16 billion, including costs linked to poorer quality of life (USD 2.65 billion), productivity loss (USD 2.16 billion) and hospital care (USD 0.05 billion). When the costs associated with maternal suicide are included, total costs increase to USD 4.93 billion.

LIMITATIONS

Several costs could not be included in the analysis because of a lack of data. The study is reliant of longitudinal data on associations between perinatal depression and anxiety and impacts on mothers and children. Therefore, no causality can be inferred.

CONCLUSION

Our findings illustrate the economic rationale for investment in this area. This is the first study that estimates the costs of perinatal mental health problems in a low- or middle-income country setting.

Rates of depressive and anxiety symptoms in the perinatal period during the COVID-19 pandemic: Comparisons between countries and with pre-pandemic data

BACKGROUND

The COVID-19 pandemic was a significant threat to perinatal mental health. This study examined differences in clinically significant depression, anxiety, and co-morbid symptoms among pregnant and postpartum women across several countries and compared prevalence of perinatal depression and anxiety before and during the pandemic in each participating country.

METHODS

Participants were 3326 pregnant and 3939 postpartum women (up to six months postpartum) living in Brazil, Chile, Cyprus, Greece, Israel, Portugal, Spain, Turkey, and the United Kingdom. An online survey was completed between June 7th and October 31st 2020, and included the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder Screener (GAD-7). The pre-pandemic studies were identified through literature review.

RESULTS

Prevalence of clinically significant depression (EPDS≥13), anxiety (GAD-7 ≥ 10), and co-morbid (EPDS≥13 and GAD-7 ≥ 10) symptoms was 26.7 %, 20 % and 15.2 %, in pregnant women, and 32.7 %, 26.6 % and 20.3 %, in postpartum women, respectively. Significant between-country differences were found in all mental health indicators in both perinatal periods. Higher levels of symptoms were observed during (versus before) the pandemic, especially among postpartum women.

LIMITATIONS

Participants were mostly highly educated and cohabiting with a partner. The online nature of the survey may have limited the participation of women from vulnerable socio-economically backgrounds.

CONCLUSIONS

Our findings expand previous literature on the negative impact of the COVID-19 pandemic on perinatal mental health, by highlighting that this may be influenced by country of residence. Mental health care policies and interventions should consider the unique needs of perinatal women in different parts of the world.

Maternal sensitivity and infant neural response to touch: an fNIRS study

The mother's attunement to her infant's emotional needs influences her use of touching behaviors during mother-infant interactions. Moreover, maternal touch appears to modulate infants' physiological responses to affective touch. However, little is known about the impact of maternal sensitivity on infants' touch processing at a brain level. This study explored the association between maternal sensitivity when infants (N = 24) were 7 months old and their patterns of cortical activation to touch at 12 months. Brain activation was measured using functional near-infrared spectroscopy. Changes in oxy-hemoglobin (HbO2) and deoxy-hemoglobin (HHb) concentrations were measured in the left somatosensory cortex and right temporal cortex while infants received two types of tactile stimulation-affective and discriminative touch. Results showed that a lower maternal sensitivity was associated with a higher HbO2 response for discriminative touch over the temporal region. Additionally, infants of less sensitive mothers tended to present a higher response in HbO2 for affective touch over the somatosensory region. These findings suggest that less sensitive interactions might result in a lower exposure to maternal touch, which can be further related to infants' neural processing of touch.

Efficacy of non-invasive brain stimulation in decreasing depression symptoms during the peripartum period: A systematic review

BACKGROUND

Non-invasive brain stimulation (NIBS) techniques have been suggested as alternative treatments to decrease depression symptoms during the perinatal period. These include brain stimulation techniques that do not require surgery and that are nonpharmacological and non-psychotherapeutic. NIBS with evidence of antidepressant effects include repetitive transcranial magnetic stimulation (rTMS), transcranial electric stimulation (TES) and electroconvulsive therapy (ECT).

OBJECTIVES

This systematic review aims to summarize evidence on NIBS efficacy, safety and acceptability in treating peripartum depression (PPD).

METHODS

We included randomized, non-randomized and case reports, that used NIBS during pregnancy and the postpartum. The reduction of depressive symptoms and neonatal safety were the primary and co-primary outcomes, respectively.

RESULTS

rTMS shows promising results for the treatment of PPD, with clinically significant decreases in depressive symptoms between baseline and end of treatment and overall good acceptability. Although the safety profile for rTMS is adequate in the postpartum, caution is warranted during pregnancy. In TES, evidence on efficacy derives mostly from single-arm studies, compromising the encouraging findings. Further investigation is necessary concerning ECT, as clinical practice relies on clinical experience and is only described in low-quality case-reports.

LIMITATIONS

The reduced number of controlled studies, the lack of complete datasets and the serious/high risk of bias of the reports warrant cautious interpretations.

CONCLUSIONS AND IMPLICATIONS

Existing evidence is limited across NIBS techniques; comparative studies are lacking, and standard stimulation parameters are yet to be established. Although rTMS benefits from the most robust research, future multicenter randomized clinical trials are needed to determine the position of each NIBS strategy within the pathways of care.

Joint attention abilities in Brazilian preterm and full-term infants

Joint attention abilities of preterm and full-term Brazilian infants were assessed at 12- and 18-months, age corrected for prematurity. Results showed that preterm infants displayed significantly lower levels of correct responses to others' bids for joint attention at both time-points, compared to full-term infants. Both groups improved their responding to joint attention from 12 to 18 months of age. Contrastingly, prematurity did not impact infants' initiating joint attention behaviors, which remained stable over time for both groups. Findings were discussed in terms of the specific mental processes involved in distinct behavioural dimensions of joint attention.

Efficacy of rTMS in decreasing postnatal depression symptoms: A systematic review

BACKGROUND

Repetitive Transcranial Magnetic Stimulation (rTMS) has been suggested as an alternative treatment to postnatal depression (PPD).

OBJECTIVES

This systematic review aims to examine and summarise evidence on rTMS efficacy in treating depression during the postnatal period.

METHODS

We included randomized and non-randomized, single arm, and case report studies, with active rTMS and theta-burst stimulation, sham rTMS, pharmacotherapy or no treatment as comparators. Participants included women with PPD, who were administered rTMS after delivery and up to 12 months postpartum. The observed outcomes were response rate and acceptability.

RESULTS

rTMS shows promising results, with clinically significant decreases in Edinburgh Postnatal Depression Scale (EPDS) scores at week 4 and an overall low risk of dropout.

LIMITATIONS

The reduced number of reports, the lack of complete datasets and the serious/high risk of bias of the studies warrant cautious interpretations.

CONCLUSIONS AND IMPLICATIONS

Despite the promising results, existing evidence on rTMS efficacy is limited, and questions remain on what the most beneficial stimulation parameters should be. Future multicentre randomized clinical trials are needed to better ascertain the clinical efficacy of rTMS in the treatment of depression in the postpartum period.

Maternal Interactive Behaviours in Parenting Children with Williams Syndrome and Autism Spectrum Disorder: Relations with Emotional/Behavioural Problems

This study compared maternal responsiveness to children with two neurodevelopmental disorders sharing different but, in some cases, overlapping social phenotypes-Williams syndrome (WS) and autism spectrum disorder (ASD)-and explored the relations between maternal responsiveness and child emotional/behavioural problems (EBP). The sample included 16 pre-schoolers with WS and 43 with ASD, and their mothers. Responsiveness was assessed during a mother-child interaction task. Mothers completed the CBCL 1½-5, providing a measure of EBP. No significant differences emerged between groups, and most dyads were characterized by less responsive behaviours. Maternal responsiveness proved related to child developmental age, but not with EBP. These results provide further insight into the rearing environment of children with neurodevelopmental disorders, highlighting the need for early relationship-based interventions.

Altered functional connectivity of the default mode network in Williams syndrome: a multimodal approach

Resting state brain networks are implicated in a variety of relevant brain functions. Importantly, abnormal patterns of functional connectivity (FC) have been reported in several neurodevelopmental disorders. In particular, the Default Mode Network (DMN) has been found to be associated with social cognition. We hypothesize that the DMN may be altered in Williams syndrome (WS), a neurodevelopmental genetic disorder characterized by an unique cognitive and behavioral phenotype. In this study, we assessed the architecture of the DMN using fMRI in WS patients and typically developing matched controls (sex and age) in terms of FC and volumetry of the DMN. Moreover, we complemented the analysis with a functional connectome approach. After excluding participants due to movement artifacts (n = 3), seven participants with WS and their respective matched controls were included in the analyses. A decreased FC between the DMN regions was observed in the WS group when compared with the typically developing group. Specifically, we found a decreased FC in a posterior hub of the DMN including the precuneus, calcarine and the posterior cingulate of the left hemisphere. The functional connectome approach showed a focalized and global increased FC connectome in the WS group. The reduced FC of the posterior hub of the DMN in the WS group is consistent with immaturity of the brain FC patterns and may be associated with the singularity of their visual spatial phenotype.

Contributions of infant vagal regulation at 1 month to subsequent joint attention abilities

Since birth, humans develop an ability to regulate their inner states and behaviors, when facing demanding situations, in order to restore calmness and engage with other persons and the surrounding environment. The present study analyzed whether 1-month infant vagal regulation to auditory stimuli was associated with later joint attention abilities-responding to and initiating joint attention-in interaction with their mothers. Twenty-three infants were assessed and measures of respiratory sinus arrhythmia-RSA (baseline and vagal tone change during auditory stimulation) were used as index of vagal regulation. At 12-months, joint attention behaviors were assessed in a 10-min toy-play mother-infant interaction. Correlational analyses showed that lower baseline RSA and larger increases in vagal tone during auditory stimulation were related to more instances of joint attention behaviors at 12 months, especially responding to joint attention. Results suggest that distinct profiles of autonomic functioning may contribute to joint attention skills.

Hemispheric asymmetries in subcortical visual and auditory relay structures in congenital deafness

Neuroplasticity - the capacity of the brain to change as a response to internal and external pressures - has been studied from a number of different perspectives. Perhaps one of the most powerful models is the study of populations that have been congenitally deprived of a sense. It has been shown that the right Auditory Cortex (AC) of congenitally deaf humans is neuroplastically modified in order to represent visual properties of a stimulus. One unresolved question is how this visual information is routed to the AC of congenitally deaf individuals. Here, we performed volumetric analysis of subcortical auditory and visual brains regions - namely the thalamus (along with three thalamic nuclei: the pulvinar, the lateral geniculate nucleus and the medial geniculate nucleus), and the inferior and superior colliculi - in deaf and hearing participants in order to identify which structures may be responsible for relaying visual information toward the altered AC. Because there is a hemispheric asymmetry in the neuroplastic changes observed in the AC of the congenitally deaf, we reasoned that subcortical structures that also showed a similar asymmetry in their total volume could have been enlisted in the effort of relaying visual information to the neuroplastically altered right AC. We show that for deaf, but not for hearing individuals, the right thalamus, right lateral geniculate nucleus and right inferior colliculus are larger than their left counterparts. These results suggest that these subcortical structures may be responsible for rerouting visual information to the AC in congenital deafness.

Are adult mentalizing abilities associated with mind-mindedness?

The precise nature of the relation between adult mentalizing abilities and parental representations of the child as a mental agent (mind-mindedness) is under current debate. While some authors state that it is the same competence expressed in different contexts, others assert that they are different constructs. This study examined the relation between mentalizing and mind-mindedness, in mothers and fathers, while investigating their potential links to socio-demographic, parental, and child variables. Participants were 74 families comprising of mother, father, and their preschool-aged child. Controlling for educational level, psychopathological symptoms, and children’s reported temperament, the relation between mentalizing and mind-mindedness was non-significant. Moreover, mentalizing and mind-mindedness were shown to have distinct correlates, supporting the proposal that they are two distinct constructs.

Concrete and relational vocabulary: comparison between Williams and Smith-Magenis syndromes

We compared the performance of two clinical groups, Williams syndrome (WS) and Smith-Magenis syndrome (SMS), in terms of concrete and relational vocabulary. We analyzed (a) whether the WS group had an advantage in concrete vocabulary when compared to the SMS group, as good concrete vocabulary knowledge is considered a hallmark of WS; (b) if spatial processing difficulties in WS would be reflected specifically in their knowledge of relational spatial vocabulary; (c) if a specific vocabulary profile could be outlined for SMS. Our results show similar performances on receptive concrete and relational vocabulary in both groups. However, and as anticipated, performance on relational space concepts was significantly lower in the WS group.

Emotion understanding in preschool children

This investigation was aimed at studying the relations between executive functions (EFs) and categorical emotion understanding while controlling for preschoolers’ IQ, language ability and theory of mind (ToM). Specifically, we wanted to analyse the association between emotion understanding and set shifting, due to the lack of studies with this EF. Data of 75 children aged 4½ years (52% boys) was collected in two laboratory visits. Emotion understanding was assessed using the Emotion Recognition Questionnaire, inhibitory control using the Head-Toes-Knees-Shoulders task and set shifting using a version of the Dimensional Change Card Sort task. IQ was evaluated using the WPPSI-R, language using the Peabody Picture Vocabulary Test – Revised; and ToM using six standardized tasks. Set shifting, but not inhibitory control, predicted emotion understanding, over and above mothers’ age, and children’s IQ, language ability, and ToM. Mothers’ age and children’s language ability were also significant predictors in the final regression model. Results suggest that the capacity to shift mental sets is linked with inter-individual differences in children’s understanding of situational causes of emotion. Therefore studying EFs as correlates of emotion understanding is an important focus of future research.

Cerebral and cerebellar MRI volumes in Williams syndrome

Individuals with Williams syndrome (WS) present a set of cognitive, affective and motor symptoms that resemble those of patients with lesions to the cerebellum. Although there is some evidence for overall structural alterations in this brain region in WS, explorations on cerebellar white matter and cerebellar cortex volumes remain rather neglected. We aimed to compare absolute and relative cerebellar volumes, as well as patterns of white matter to cortex volumes in this brain region, between a group of individuals with WS and a group of healthy controls. T1-weighted magnetic resonance images were acquired in 17 individuals with WS and in 15 typically developing individuals. Our results showed that even though individuals from the clinical group had significantly smaller cerebrums (and cerebellums), cerebellar volumes relative to intracranial volumes were significantly enlarged. In addition, while gray matter was relatively spared and white matter disproportionately reduced in the cerebrum in WS, relative cerebellar cortex and white matter volumes were preserved. These findings support the hypothesis that volume alterations in the cerebellum are associated with the cognitive, affective and motor profiles in WS.

Child and mother mental-state talk in shared pretense as predictors of children's social symbolic play abilities at age 3

This study investigated relations between mother and child (N=49) mental-state talk during shared pretense and children's social symbolic play at age 3. Social symbolic play was not related to mothers' mental-state talk. In contrast, children's own use of desire-state talk in shared pretense was a better predictor of social symbolic play than their general use of mental-state talk, even after accounting for general verbal ability as well as mothers' use of desires terms.

CONCLUSION

These results highlight for the first time a link between children's references to desires and their performance on social symbolic play at age 3 years - a social cognitive ability thought to precede theory of mind.

How executive functions are related to intelligence in Williams syndrome

Williams syndrome is characterized by impairments in executive functions (EFs). However, it remains unknown how distinct types of EFs relate to intelligence in this syndrome. The present study analyzed performance on working memory, inhibiting and shifting, and its links to IQ in a sample of 17 individuals with WS, and compared them with a group of 17 typically developing individuals matched on chronological age and gender. In conclusion, our results suggest that working memory, inhibiting, and shifting relate differently to intelligence in WS as well as in typical development, with working memory being the EF most closely related to intelligence in both groups. Notably, the magnitude of the associations between the three EFs and IQ was substantially higher in the WS group than in the TD group, bringing further confirmation to the notion that frontal lobe impairments may produce a general compromise of several EFs.

Cognitive functioning in children and adults with Smith-Magenis syndrome

Smith-Magenis Syndrome (SMS) is a genetic neurodevelopmental disorder caused by a microdeletion on chromosome 17p11.2. This syndrome is characterized by a distinctive profile of physical, medical and neuropsychological characteristics. The latter include general mental disability, with the majority of individuals falling within the mild to moderate range. This study reports a detailed cognitive assessment of children and adults with SMS with the use of the Wechsler intelligence scales at three distinct levels of analysis: full scale IQ, factorial indices, and subtests. Child and adult samples were each compared to samples of age and gender-matched typically developing individuals. To our knowledge, this is the first study to systematically analyse the cognitive profile of individuals with SMS in Southern Europe. The present study confirmed mental disability, particularly within the moderate category, as a consistent feature of children and adults with SMS. Furthermore, both child and adult samples evidenced significant impairments in all four indices when compared with their typically developing counterparts. A specific pattern of strengths and weaknesses was discernible for both samples, with Verbal Comprehension emerging as a relative strength, whereas Working Memory appeared as a relative weakness. Finally, with the exception of two subtests in the perceptual domain, we found no evidence for a general cognitive decline with age.

Individual and relational contributions to parallel and joint attention in infancy

OBJECTIVE

This study examined the contributions of maternal bids for joint attention, relationship quality, and infant characteristics, to individual differences in infants' parallel and joint attention.

METHOD

Fifty-two 10-month-olds and their mothers were assessed in order to investigate concurrent predictors of infant parallel attention, responding to joint attention, and initiating joint attention.

RESULTS

Parallel attention was predicted by infants' higher mental development, low expression of negative emotionality, and maternal entertaining behaviors. Responding to joint attention was marginally predicted by total maternal bids for joint attention. Initiating joint attention was predicted by the infants' low expression of negative emotionality, as well as marginally predicted by fewer maternal teaching behaviors.

CONCLUSION

These results further the understanding of the factors influencing infant parallel as well as joint attention.

Safety of dobutamine-atropine stress echocardiography: A prospective experience of 4,033 consecutive studies

Dobutamine-atropine stress echocardiography (DASE) is an established method and has been shown to be accurate for the detection of coronary artery disease. Still, there are few large clinical studies that analyze the safety of DASE in general or the safety of performing it on an ambulatory basis. Most studies use a target heart rate as the primary end point regardless of whether asymptomatic ischemia occurs. Such studies have shown a serious cardiac event rate of approximately 0.3%. We prospectively studied 4,033 consecutive patients on an ambulatory basis and in the hospital with the use of DASE from July 1991 to December 1998. All tests were performed by an experienced physician, and all clinical and DASE data were stored in a large database organized at the beginning of the study. Dobutamine was infused in scalar doses of 5, 10, 20, 30, and 40 microg/kg per minute in 3-minute stages. Development of a new wall motion abnormality, achievement of 85% of target heart, and end of the DASE infusion protocol were used as an end point. If 85% of the target heart rate was not achieved, atropine was infused up to 1 mg in the absence of myocardial ischemia, which was used in 1,280 studies. There were 3,645 diagnostic tests, and 388 (10%) were found to be nondiagnostic. This result was due to poor image quality in 115 (3%), end of protocol in negative-submaximal examinations in 124 (3%), and limiting side effects in 149 (4%). Thirty-seven percent of the tests showed positive results for myocardial ischemia. Major test-related cardiac complications occurred in 10 (0.25%) patients and included 1 ventricular fibrillation, 1 case of myocardial infarction, and 8 cases of sustained ventricular tachycardia. Atropine poisoning was observed in 5 (0.12%) patients. No deaths occurred as a direct or indirect consequence of DASE. We conclude that dobutamine-atropine stress echocardiography is a reasonably safe method for detection of coronary artery disease in the hospital or in an ambulatory basis. The use of new wall motion abnormality as 1 of the end points may prevent further ischemia-related complications.

Mycosis fungoides with early central nervous system involvement

The authors present a rare case of mycosis fungoides with early central nervous system involvement mimicking an intramedullary tumour in a 38- year-old white male.