Impact of colocated behavioral health on OB-GYN clinicians' rate of perinatal behavioral health diagnosis and psychotropic prescription

OBJECTIVE

To examine the association of colocated behavioral health(BH) care with rates of OB-GYN clinician coding of BH diagnoses and BH medications.

METHOD

Using 2 years of EMR data from perinatal individuals treated across 24 OB-GYN clinics, we tested the hypothesis that colocated BH care would increase rates of OB-GYN BH diagnoses and psychotropic prescription.

RESULTS

Psychiatrist integration(0.1 FTE) was associated with 45.7% higher odds of OB-GYN coding for BH diagnoses and BH clinician integration was associated with 25% lower odds of OB-GYN BH diagnosis and 37.7% lower odds of BH medication prescription. Non-white patients had 28-74% and 43-76% lower odds of having a BH diagnosis and a BH medication ordered, respectively. The most common diagnoses were anxiety and depressive disorders(60%) and the most prescribed BH medications were SSRIs(86%).

CONCLUSIONS

OB-GYN clinicians made fewer BH diagnoses and prescribed fewer psychotropics after 2.0 FTE BH clinician integration, a possible indication of external referrals for BH treatment. Non-white patients received BH diagnoses and medications less often than white patients. Future research in real world implementation of BH integration in OB-GYN clinics should examine fiscal strategies that support BH care manager-OB-GYN collaboration as well as methods to ensure equitable delivery of BH care.

Preconception interpersonal personality features predict postpartum maternal parenting behaviors

Individual differences in personality traits affect the quality of social relationships. The parent-child relationship is among the most impactful social relationships in an individual's life, and positive parenting behaviors are known to support positive child development. The present study aimed to identify personality predictors-measured prior to conception at age 16-on later positive parenting behaviors. Young women (n = 207; 83.5% Black or multiracial; 86.9% receiving public assistance) who were followed since childhood as part of a prospective longitudinal study were observed interacting with their infants 4 months postpartum. We tested prospective associations between personality factors relevant to the quality and maintenance of social relationships-empathy, callousness, and rejection sensitivity-and coded dimensions of parenting behavior: maternal warmth, responsiveness, and mental state talk. We additionally examined potential moderating effects of infant affect on the relations between personality and parenting behavior. Results indicated that preconception empathy predicted later maternal warmth and responsivity, whereas preconception callousness was inversely associated with maternal warmth. The association between rejection sensitivity and maternal mental state talk was moderated by infant affect, consistent with a "goodness-of-fit" framework. The present study is the first to our knowledge to report associations between preconception personality and later parenting behaviors. The findings suggest that a woman's personality traits in adolescence, potentially years before she becomes a mother, can predict her behavior during interactions with her infant. Clinically, findings suggest the potential for interventions in adolescence to influence later parenting behavior and ultimately impact children's developmental outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An intensive outpatient program for suicidal college students

Objective: College counseling centers (CCCs) have limited capacity to accommodate high-risk students who need more intensive care than traditional outpatient treatment. We describe an Intensive Outpatient Program (IOP) to meet the specialized needs of suicidal undergraduates. Participants: Suicidal undergraduates aged 18-24. Methods: Fact-gathering meetings with local universities confirmed high need for prompt access to IOP care for students presenting in crisis at CCCs and emergency rooms, and post-inpatient discharge. We thus iteratively designed and implemented the College Option Services for Teens at Risk (COSTAR) IOP. Results: The 6-week program includes initial diagnostic evaluation and risk assessment followed by weekly skills groups, individual therapy, and medication management. Between September 2017 and January 2020, 148 students (M age = 19.7) attended an average of 5.7 COSTAR group sessions (SD = 4.7). Conclusions: A specialty IOP for suicidal college students holds promise in a stepped care approach for at-risk college students.

A Transactional Model of Infant Still-Face Response and Maternal Behavior During the First Year

The present study takes a transactional approach to extend understanding of temporal relations between parenting behaviors and infant response to the face‐to‐face still‐face, a widely used method assessing infants’ affective and behavioral response to a violation of social expectations. A low‐income, urban sample of 180 mothers and infants participated when infants were 4 and 6 months old. Directional relations between infants’ still‐face response (i.e., change in affect and gaze from interaction to still face) and three parenting dimensions were examined using cross‐lagged structural equation models. Infant still‐face response predicted later parenting behavior, while the reverse association was not significant. Specifically, infants with a greater reduction in positive affect from interaction to still face had parents with more positive parenting and less negative parenting behaviors 2 months later, controlling for prior parenting and concurrent infant behavior. Furthermore, infants who increased gaze to mother from interaction to still face had mothers who used more mental state talk 2 months later. Findings underscore the importance of examining transactional relations between infant and parent behaviors, and in particular highlight the influence of infants on parents. Acknowledging these infant‐effects is critical to the development and implementation of interventions targeting parent‐infant interactions.

Postpartum depressive symptoms moderate the link between mothers' neural response to positive faces in reward and social regions and observed caregiving

Postpartum depression may disrupt socio-affective neural circuitry and compromise provision of positive parenting. Although work has evaluated how parental response to negative stimuli is related to caregiving, research is needed to examine how depressive symptoms during the postpartum period may be related to neural response to positive stimuli, especially positive faces, given depression’s association with biased processing of positive faces. The current study examined the association between neural response to adult happy faces and observations of maternal caregiving and the moderating role of postpartum depression, in a sample of 18- to 22-year old mothers (n = 70) assessed at 17 weeks (s.d. = 4.7 weeks) postpartum. Positive caregiving was associated with greater precuneus and occipital response to positive faces among mothers with lower depressive symptoms, but not for those with higher symptoms. For mothers with higher depressive symptoms, greater ventral and dorsal striatal response to positive faces was associated with more positive caregiving, whereas the opposite pattern emerged for mothers with lower symptoms. There was no association between negative caregiving and neural response to positive faces or negative faces. Processing of positive stimuli may be an important prognostic target in mothers with depressive symptoms, given its link with healthy caregiving behaviors.

Mood symptoms in pregnant and postpartum women with bipolar disorder: a naturalistic study

OBJECTIVE

We conducted a prospective naturalistic study of pregnant women with bipolar disorder (BD) to evaluate symptoms of BD across childbearing and assess whether pharmacotherapy reduced their severity.

METHODS

Assessments were scheduled at 20, 30, and 36 weeks' gestation and 2, 12, 26, and 52 weeks postpartum. Symptoms were assessed using the Structured Interview Guide for the Hamilton Depression Rating Scale-Atypical Depression Supplement (SIGH-ADS) and Mania Rating Scale (MRS).

RESULTS

Pregnant women (N=152) with BD were evaluated; 88 women (58%) were treated and 64 untreated (42%) with psychotropic drugs during pregnancy. Among the 88 women treated, 23 (26%) discontinued their medication in the first trimester and the remaining 65 (74%) were exposed throughout pregnancy or in the second and third trimesters. More than two-thirds (73%) of the women who remained in the study took psychotropic agents postpartum. The mean scores on the SIGH-ADS were in the mild range of depressive symptoms in both the psychotropic-treated and untreated groups in both pregnancy and postpartum. The majority of women had no or few symptoms of mania. Of the pregnant women treated with psychotropic agents, 66% received a guideline-concordant drug, and 34% received either antidepressant monotherapy (for BD I) or mono- or polypharmacy with a variety of other agents.

CONCLUSIONS

This sample of perinatal women with BD was characterized by mild residual symptoms of depression independent of pharmacotherapy, which poses a risk for recurrence and impaired parenting. The treatment of childbearing women with BD deserves urgent clinical and research attention to improve psychiatric outcomes.

Telephone-Based Depression Care Management for Postpartum Women: A Randomized Controlled Trial

OBJECTIVE

With a period prevalence of 21.9% in the year after birth, depression is a common complication of childbearing. We assessed the impact of telephone-delivered depression care management (DCM) on symptom levels, health service utilization, and functional status 3, 6, and 12 months postpartum.

METHODS

The randomized controlled trial was conducted at the University of Pittsburgh, Pittsburgh, Pennsylvania, from March 2006 through September 2010. Women (N = 628) who screened positive for depression (a score of 10 or greater on the Edinburgh Postnatal Depression Scale) 4 to 6 weeks postpartum were evaluated with the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen and enrolled in a randomized trial of DCM compared to enhanced usual care (EUC). Clinicians conducted telephone contacts to educate, assist with treatment decisions, monitor symptoms, facilitate access to services, and encourage links to community resources. Independent evaluators collected symptom scores, functional status, and health services use at 3, 6, and 12 months postpartum. Primary outcome was reduction of symptoms as measured by the Structured Interview Guide for the Hamilton Depression Rating Scale with Atypical Depression Supplement.

RESULTS

Mean depressive symptom and function scores significantly improved (by greater than 50%) in both groups of women but did not differ by DCM versus EUC assignment. Health services use was similar in women randomly assigned to DCM compared to EUC. Women with childhood sexual abuse responded significantly more favorably to DCM on depression and functional measures (all P values < .02).

CONCLUSIONS

Both DCM and EUC favorably impacted depression symptom levels and function. The subgroup of women with childhood sexual abuse benefited significantly more from DCM compared to the EUC condition. Regular telephone availability of a clinician is a resource that appears to be particularly therapeutic to women with childhood sexual abuse.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00282776.

Predicting adolescent postpartum caregiving from trajectories of depression and anxiety prior to childbirth: a 5-year prospective study

Symptoms of depression and anxiety in pregnancy have been linked to later impaired caregiving. However, mood symptoms are often elevated in pregnancy and may reflect motherhood-specific concerns. In contrast, little is known about the effects of prepregnancy depression and anxiety on postpartum caregiving. Understanding these developmental risk factors is especially important when childbearing also occurs during adolescence. The sample comprised 188 adolescent mothers (ages 12-19 years) who had participated in a longitudinal study since childhood. Mothers were observed in face-to-face interaction with the infant at 4 months postpartum, and caregiving behaviors (sensitivity, hostile-intrusive behavior, and mental state talk) were coded independently. Data on self-reported depression and anxiety gathered in the 5 years prior to childbirth were drawn from the large-scale longitudinal study. Parallel process latent growth curve models revealed unique effects of distal anxiety and slow decline in anxiety over time on lower levels of maternal mental state talk after accounting for the overlap with depression development. Depressive symptoms showed significant stability from distal measurement to the postpartum period, but only concurrent postpartum mood was associated with poorer quality of maternal speech. The results highlight specific targets for well-timed preventive interventions with vulnerable dyads.

Right Frontoinsular Cortex and Subcortical Activity to Infant Cry Is Associated with Maternal Mental State Talk

The study objective was to examine neural correlates of a specific component of human caregiving: maternal mental state talk, reflecting a mother's proclivity to attribute mental states and intentionality to her infant. Using a potent, ecologically relevant stimulus of infant cry during fMRI, we tested hypotheses that postpartum neural response to the cry of "own" versus a standard "other" infant in the right frontoinsular cortex (RFIC) and subcortical limbic network would be associated with independent observations of maternal mental state talk. The sample comprised 76 urban-living, low socioeconomic mothers (82% African American) and their 4-month-old infants. Before the fMRI scan, mothers were filmed in face-to-face interaction with their infant, and maternal behaviors were coded by trained researchers unaware of all other information about the participants. The results showed higher functional activity in the RFIC to own versus other infant cry at the group level. In addition, RFIC and bilateral subcortical neural activity (e.g., thalamus, amygdala, hippocampus, putamen) was associated positively with maternal mental state talk but not with more global aspects of observed caregiving. These findings held when accounting for perceptual and contextual covariates, such as maternal felt distress, urge to help, depression severity, and recognition of own infant cry. Our results highlight the need to focus on specific components of caregiving to advance understanding of the maternal brain. Future work will examine the predictive utility of this neural marker for mother-child function.

SIGNIFICANCE STATEMENT

The current study advances extant literature examining the neural underpinning of early parenting behavior. The findings highlight the special functional importance of the right frontoinsular cortex-thalamic-limbic network in a mother's proclivity to engage in mental state talk with her preverbal infant, a circumscribed aspect of maternal caregiving purported to be a prerequisite of sensitive and responsive caregiving. These associations existed specifically for maternal mentalizing behavior and were not evident for more generic aspects of caregiving in this urban sample of 76 postpartum mothers. Finally, the findings were robust even when controlling for potential demographic, perceptual, and contextual confounds, supporting the notion that these regions constitute an innate, specialized maternal mentalizing network.

In search of neural endophenotypes of postpartum psychopathology and disrupted maternal caregiving

This is a selective review that provides the context for the study of perinatal affective disorder mechanisms and outlines directions for future research. We integrate existing literature along neural networks of interest for affective disorders and maternal caregiving: (i) the salience/fear network; (ii) the executive network; (iii) the reward/social attachment network; and (iv) the default mode network. Extant salience/fear network research reveals disparate responses and corticolimbic coupling to various stimuli based upon a predominantly depressive versus anxious (post-traumatic stress disorder) clinical phenotype. Executive network and default mode connectivity abnormalities have been described in postpartum depression (PPD), although studies are very limited in these domains. Reward/social attachment studies confirm a robust ventral striatal response to infant stimuli, including cry and happy infant faces, which is diminished in depressed, insecurely attached and substance-using mothers. The adverse parenting experiences received and the attachment insecurity of current mothers are factors that are associated with a diminution in infant stimulus-related neural activity similar to that in PPD, and raise the need for additional studies that integrate mood and attachment concepts in larger study samples. Several studies examining functional connectivity in resting state and emotional activation functional magnetic resonance imaging paradigms have revealed attenuated corticolimbic connectivity, which remains an important outcome that requires dissection with increasing precision to better define neural treatment targets. Methodological progress is expected in the coming years in terms of refining clinical phenotypes of interest and experimental paradigms, as well as enlarging samples to facilitate the examination of multiple constructs. Functional imaging promises to determine neural mechanisms underlying maternal psychopathology and impaired caregiving, such that earlier and more precise detection of abnormalities will be possible. Ultimately, the discovery of such mechanisms will promote the refinement of treatment approaches toward maternal affective disturbance, parenting behaviours and the augmentation of parenting resiliency.

Disrupted posterior cingulate-amygdala connectivity in postpartum depressed women as measured with resting BOLD fMRI

Disengagement of emotion regulation circuits was previously shown in depressed mothers and was hypothesized to underlie the impaired maternal-infant sensitivity described in postpartum depression (PPD). We hypothesized similarly reduced resting-state functional connectivity in default mode network (DMN) regions involved in social cognition in PPD. Resting-state functional MRI, clinical and mother-infant attachment data were obtained from 14 unmedicated postpartum women with major depression and 23 healthy postpartum women. Posterior cingulate cortex (PCC) time series were extracted, filtered between 0.007 and 0.08 Hz and used as regressors in a whole brain general linear model analysis. PCC-right amygdala connectivity was significantly disrupted in depressed compared to healthy mothers for low-frequency neural activity, showing a negative (inverse) coupling in the depressed group but not in the controls. PCC-right amygdala connectivity was positively correlated with PCC-parahippocampus connectivity. Resting connectivity patterns of positive co-activations in postpartum women mirrored the canonical DMN. These findings of reduced PCC-amygdala coupling raise the possibility that PPD might involve the disruption of outward, preventative aspects of self-relevant thought and theory of mind/empathy processes. Further integrated studies of neural connectivity and these cognitive/behavioral dimensions are warranted.

Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings

IMPORTANCE

The period prevalence of depression among women is 21.9% during the first postpartum year; however, questions remain about the value of screening for depression.

OBJECTIVES

To screen for depression in postpartum women and evaluate positive screen findings to determine the timing of episode onset, rate and intensity of self-harm ideation, and primary and secondary DSM-IV disorders to inform treatment and policy decisions.

DESIGN

Sequential case series of women who recently gave birth.

SETTING

Urban academic women's hospital.

PARTICIPANTS

During the maternity hospitalization, women were offered screening at 4 to 6 weeks post partum by telephone. Screen-positive women were invited to undergo psychiatric evaluations in their homes.

MAIN OUTCOMES AND MEASURES

A positive screen finding was an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher. Self-harm ideation was assessed on EPDS item 10: "The thought of harming myself has occurred to me" (yes, quite often; sometimes; hardly ever; never). Screen-positive women underwent evaluation with the Structured Clinical Interview for DSM-IV for Axis I primary and secondary diagnoses.

RESULTS

Ten thousand mothers underwent screening, with positive findings in 1396 (14.0%); of these, 826 (59.2%) completed the home visits and 147 (10.5%) completed a telephone diagnostic interview. Screen-positive women were more likely to be younger, African American, publicly insured, single, and less well educated. More episodes began post partum (40.1%), followed by during pregnancy (33.4%) and before pregnancy (26.5%). In this population, 19.3% had self-harm ideation. All mothers with the highest intensity of self-harm ideation were identified with the EPDS score of 10 or higher. The most common primary diagnoses were unipolar depressive disorders (68.5%), and almost two-thirds had comorbid anxiety disorders. A striking 22.6% had bipolar disorders.

CONCLUSIONS AND RELEVANCE

The most common diagnosis in screen-positive women was major depressive disorder with comorbid generalized anxiety disorder. Strategies to differentiate women with bipolar from unipolar disorders are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00282776.

Postpartum and depression status are associated with lower [[¹¹C]raclopride BP(ND) in reproductive-age women

The early postpartum period is associated with increased risk for affective and psychotic disorders. Because maternal dopaminergic reward system function is altered with perinatal status, dopaminergic system dysregulation may be an important mechanism of postpartum psychiatric disorders. Subjects included were non-postpartum healthy (n=13), postpartum healthy (n=13), non-postpartum unipolar depressed (n=10), non-postpartum bipolar depressed (n=7), postpartum unipolar (n=13), and postpartum bipolar depressed (n=7) women. Subjects underwent 60 min of [¹¹C]raclopride-positron emission tomography imaging to determine the nondisplaceable striatal D₂/₃ receptor binding potential (BP(ND)). Postpartum status and unipolar depression were associated with lower striatal D₂/₃ receptor BP(ND) in the whole striatum (p=0.05 and p=0.02, respectively) that reached a maximum of 7-8% in anteroventral striatum for postpartum status (p=0.02). Unipolar depression showed a nonsignificant trend toward being associated with 5% lower BP(ND) in dorsal striatum (p=0.06). D₂/₃ receptor BP(ND) did not differ significantly between unipolar depressed and healthy postpartum women or between bipolar and healthy subjects; however, D₂/₃ receptor BP(ND) was higher in dorsal striatal regions in bipolar relative to unipolar depressives (p=0.02). In conclusion, lower striatal D₂/₃ receptor BP(ND) in postpartum and unipolar depressed women, primarily in ventral striatum, and higher dorsal striatal D₂/₃ receptor BP(ND) in bipolar relative to unipolar depressives reveal a potential role for the dopamine (DA) system in the physiology of these states. Further studies delineating the mechanisms underlying these differences in D₂/₃ receptor BP(ND), including study of DA system responsivity to rewarding stimuli, and increasing power to assess unipolar vs bipolar-related differences, are needed to better understand the affective role of the DA system in postpartum and depressed women.

Medial prefrontal cortex serotonin 1A and 2A receptor binding interacts to predict threat-related amygdala reactivity

BACKGROUND

The amygdala and medial prefrontal cortex (mPFC) comprise a key corticolimbic circuit that helps shape individual differences in sensitivity to threat and the related risk for psychopathology. Although serotonin (5-HT) is known to be a key modulator of this circuit, the specific receptors mediating this modulation are unclear. The colocalization of 5-HT1A and 5-HT2A receptors on mPFC glutamatergic neurons suggests that their functional interactions may mediate 5-HT effects on this circuit through top-down regulation of amygdala reactivity. Using a multimodal neuroimaging strategy in 39 healthy volunteers, we determined whether threat-related amygdala reactivity, assessed with blood oxygen level-dependent functional magnetic resonance imaging, was significantly predicted by the interaction between mPFC 5-HT1A and 5-HT2A receptor levels, assessed by positron emission tomography.

RESULTS

5-HT1A binding in the mPFC significantly moderated an inverse correlation between mPFC 5-HT2A binding and threat-related amygdala reactivity. Specifically, mPFC 5-HT2A binding was significantly inversely correlated with amygdala reactivity only when mPFC 5-HT1A binding was relatively low.

CONCLUSIONS

Our findings provide evidence that 5-HT1A and 5-HT2A receptors interact to shape serotonergic modulation of a functional circuit between the amygdala and mPFC. The effect of the interaction between mPFC 5-HT1A and 5-HT2A binding and amygdala reactivity is consistent with the colocalization of these receptors on glutamatergic neurons in the mPFC.

Abnormally reduced dorsomedial prefrontal cortical activity and effective connectivity with amygdala in response to negative emotional faces in postpartum depression

OBJECTIVE

Postpartum major depression is a significant public health problem that strikes 15% of new mothers and confers adverse consequences for mothers, children, and families. The neural mechanisms involved in postpartum depression remain unknown, but brain processing of affective stimuli appears to be involved in other affective disorders. The authors examined activity in response to negative emotional faces in the dorsomedial pre-frontal cortex and amygdala, key emotion regulatory neural regions of importance to both mothering and depression.

METHOD

Postpartum healthy mothers (N=16) and unmedicated depressed mothers (N=14) underwent functional magnetic resonance imaging blood-oxygen-level-dependent acquisition during a block-designed face versus shape matching task. A two-way analysis of variance was performed examining main effects of condition and group and group-by-condition interaction on activity in bilateral dorsomedial prefrontal cortical and amygdala regions of interest.

RESULTS

Depressed mothers relative to healthy mothers had significantly reduced left dorsomedial prefrontal cortical face-related activity. In depressed mothers, there was also a significant negative correlation between left amygdala activity and postpartum depression severity and a significant positive correlation between right amygdala activity and absence of infant-related hostility. There was reliable top-down connectivity from the left dorsomedial prefrontal cortex to the left amygdala in healthy, but not depressed, mothers.

CONCLUSIONS

Significantly diminished dorsomedial prefrontal cortex activity and dorsomedial prefrontal cortical-amygdala effective connectivity in response to negative emotional faces may represent an important neural mechanism, or effect, of postpartum depression. Reduced amygdala activity in response to negative emotional faces is associated with greater postpartum depression severity and more impaired maternal attachment processes in postpartum depressed mothers.

Major depression and antidepressant treatment: impact on pregnancy and neonatal outcomes

OBJECTIVE

Selective serotonin reuptake inhibitor (SSRI) use during pregnancy incurs a low absolute risk for major malformations; however, other adverse outcomes have been reported. Major depression also affects reproductive outcomes. This study examined whether 1) minor physical anomalies, 2) maternal weight gain and infant birth weight, 3) preterm birth, and 4) neonatal adaptation are affected by SSRI or depression exposure.

METHOD

This prospective observational investigation included maternal assessments at 20, 30, and 36 weeks of gestation. Neonatal outcomes were obtained by blinded review of delivery records and infant examinations. Pregnant women (N=238) were categorized into three mutually exclusive exposure groups: 1) no SSRI, no depression (N=131); 2) SSRI exposure (N=71), either continuous (N=48) or partial (N=23); and 3) major depressive disorder (N=36), either continuous (N=14) or partial (N=22). The mean depressive symptom level of the group with continuous depression and no SSRI exposure was significantly greater than for all other groups, demonstrating the expected treatment effect of SSRIs. Main outcomes were minor physical anomalies, maternal weight gain, infant birth weight, pregnancy duration, and neonatal characteristics.

RESULTS

Infants exposed to either SSRIs or depression continuously across gestation were more likely to be born preterm than infants with partial or no exposure. Neither SSRI nor depression exposure increased risk for minor physical anomalies or reduced maternal weight gain. Mean infant birth weights were equivalent. Other neonatal outcomes were similar, except 5-minute Apgar scores.

CONCLUSIONS

For depressed pregnant women, both continuous SSRI exposure and continuous untreated depression were associated with preterm birth rates exceeding 20%.

Medial prefrontal cortex 5-HT(2A) density is correlated with amygdala reactivity, response habituation, and functional coupling

Feedback inhibition of the amygdala via medial prefrontal cortex (mPFC) is an important component in the regulation of complex emotional behaviors. The functional dynamics of this corticolimbic circuitry are, in part, modulated by serotonin (5-HT). Serotonin 2A (5-HT(2A)) receptors within the mPFC represent a potential molecular mechanism through which 5-HT can modulate this corticolimbic circuitry. We employed a multimodal neuroimaging strategy to explore the relationship between threat-related amygdala reactivity, assessed using blood oxygen level-dependent functional magnetic resonance imaging, and mPFC 5-HT(2A) density, assessed using [(18)F]altanserin positron emission tomography in 35 healthy adult volunteers. We observed a significant inverse relationship wherein greater mPFC 5-HT(2A) density was associated with reduced threat-related right amygdala reactivity. Remarkably, 25-37% of the variability in amygdala reactivity was explained by mPFC 5-HT(2A) density. We also observed a positive correlation between mPFC 5-HT(2A) density and the magnitude of right amygdala habituation. Furthermore, functional coupling between the amygdala and mPFC was positively correlated with 5-HT(2A) density suggesting that effective integration of emotionally salient information within this corticolimbic circuitry may be modulated, at least in part, by mPFC 5-HT(2A). Collectively, our results indicate that mPFC 5-HT(2A) is strongly associated with threat-related amygdala reactivity as well as its temporal habituation and functional coupling with prefrontal regulatory regions.

Serotonin-1A receptor imaging in recurrent depression: replication and literature review

INTRODUCTION

Serotonin-1A receptor (5-HT1AR) function appears to be decreased in major depressive disorder (MDD) based on physiological responses to 5-HT1AR agonists in vivo and to 5-HT1AR binding in brain tissues postmortem or antemortem. We have previously assessed 5-HT1AR binding potential (BP) in depression using positron emission tomography (PET) and [carbonyl-(11)C]WAY-100635, and we have demonstrated reduced 5-HT1AR BP in the mesiotemporal cortex (MTC) and raphe in depressives with primary recurrent familial mood disorders (n=12) versus controls (n=8) [Drevets WC, Frank E, Price JC, Kupfer DJ, Holt D, Greer PJ, Huang Y, Gautier C, Mathis C. PET imaging of serotonin 1A receptor binding in depression. Biol Psychiatry 1999;46(10):1375-87]. These findings were replicated by some, but not other, studies performed in depressed samples that were more generally selected using criteria for MDD. In the current study, we attempted to replicate our previous findings in an independent sample of subjects selected according to the criteria for primary recurrent depression applied in our prior study.

METHODS

Using PET and [carbonyl-(11)C]WAY-100635, 5-HT1AR BP was assessed in 16 depressed subjects and 8 healthy controls.

RESULTS

Mean 5-HT1AR BP was reduced by 26% in the MTC (P<.005) and by 43% in the raphe (P<.001) in depressives versus controls.

CONCLUSIONS

These data replicate our original findings, which showed that BP was reduced by 27% in the MTC (P<.025) and by 42% in the raphe (P<.02) in depression. The magnitudes of these reductions in 5-HT1AR binding were similar to those found postmortem in 5-HT1AR mRNA concentrations in the hippocampus in MDD [López JF, Chalmers DT, Little KY, Watson SJ. Regulation of serotonin 1A, glucocorticoid, and mineralocorticoid receptor in rat and human hippocampus: implications for neurobiology of depression. Biol Psychiatry 1998;43:547-73] and in 5-HT1AR-binding capacity in the raphe in depressed suicide victims [Arango V, Underwood MD, Boldrini M, Tamir H, Kassir SA, Hsiung S, Chen JJ, Mann JJ. Serotonin 1A receptors, serotonin transporter binding and serotonin transporter mRNA expression in the brainstem of depressed suicide victims. Neuropsychopharmacology 2001;25(6):892-903]. There exists disagreement within the literature, however, regarding the presence and direction of 5-HT1AR-binding abnormalities in depression, which may be explained in some cases by differences in anatomical location (e.g., [Stockmeier CA, Shapiro LA, Dilley GE, Kolli TN, Friedman L, Rajkowska G. Increase in serotonin-1A autoreceptors in the midbrain of suicide victims with major depression--postmortem evidence for decreased serotonin activity. J Neurosci 1998;18(18):7394-401]) and in other cases by pathophysiological heterogeneity within MDD (e.g., some depressives hypersecrete cortisol, which would be expected to down-regulate 5-HT1AR expression [López JF, Chalmers DT, Little KY, Watson SJ. Regulation of serotonin 1A, glucocorticoid, and mineralocorticoid receptor in rat and human hippocampus: implications for neurobiology of depression. Biol Psychiatry 1998;43:547-73]). Antidepressant drug treatment does not alter these abnormalities in 5-HT1AR binding [Sargent PA, Kjaer KH, Bench CJ, Rabiner EA, Messa C, Meyer J, Gunn RN, Grasby PM, Cowen PJ. Brain serotonin1A receptor binding measured by positron emission tomography with [11C]WAY-100635: effects of depression and antidepressant treatment. Arch Gen Psychiatry 2000;57(2):174-80; Moses-Kolko EL, Price JC, Thase ME, Meltzer CC, Kupfer DJ, Mathis CA, Bogers WD, Berman SR, Houck PR, Schneider TN, Drevets WC. Measurement of 5-HT1A receptor binding in depressed adults before and after antidepressant drug treatment using positron emission tomography and [11C]WAY-100635. Synapse 2007;61(7):523-30] but may compensate for blunted 5-HT1AR function by increasing post-synaptic 5-HT1AR transmission [Chaput Y, de Montigny C, Blier P. Presynaptic and postsynaptic modifications of the serotonin system by long-term administration of antidepressant treatments. An in vivo electrophysiologic study in the rat. Neuropsychopharmacology 1991;5(4):219-29].

Measurement of 5-HT1A receptor binding in depressed adults before and after antidepressant drug treatment using positron emission tomography and [11C]WAY-100635

OBJECTIVE

To assess effects of chronic antidepressant drug treatment on serotonin type-1A receptor (5-HT(1A)R) binding potential (BP) in major depressive disorder.

METHODS

Depressed subjects (n = 27) were imaged using PET and [(11)C]WAY-100635 at baseline and following a median of 9.4 weeks of treatment with selective serotonin reuptake inhibitor or dual reuptake inhibitor antidepressant agents. Fifteen subjects had complete pre- and post-treatment scan data. The 5-HT(1A)R BP was derived from the tissue time-radioactivity concentrations from regions-of-interest defined a priori, using a simplified reference tissue model (SRTM), and in a subset of subjects, compartmental modeling (CMOD).

RESULTS

Chronic treatment had no effect on pre- or post-synaptic 5-HT(1A)R BP, as confirmed by both the SRTM and CMOD analyses. These results were unaffected by treatment response status and were consistent across brain regions. Among the 22 subjects for whom the clinical response-to-treatment was established, the treatment nonresponders (n = 7) had higher baseline BP values in the left (P = 0.01) and right orbital cortex (P = 0.02) than the responders (n = 15).

CONCLUSIONS

Chronic antidepressant drug treatment did not significantly change cerebral 5-HT(1A)R binding, consistent with preclinical evidence that the alterations in serotonergic function associated with antidepressant drug administration are not accompanied by changes in 5-HT(1A)R density. Higher baseline 5-HT(1A)R binding was associated with poorer response to treatment.

Serotonin 1A receptor reductions in postpartum depression: a positron emission tomography study

OBJECTIVE

To measure brain serotonin-1A (5HT1A) receptor binding potential (BP) in healthy and depressed postpartum women.

DESIGN

5HT1A receptor BP was measured with positron emission tomography by using [(11)C]WAY100635 a single time. Multivariate analysis of variance was used to determine depression effects on 5HT1A receptor BP in relevant brain regions.

SETTING

An academic research environment.

PATIENT(S)

Seven postpartum healthy controls and nine postpartum depressed (PD) subjects with perinatal (antepartum or postpartum) depression onset. Of the nine PD subjects, five had unipolar depression, and four had bipolar disorder.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

5HT1A receptor BP.

RESULT(S)

Age, time since delivery, and reproductive hormones did not differ between groups. Postsynaptic 5HT1A receptor binding in postpartum depression was reduced 20%-28% relative to controls, with most significant reductions in anterior cingulate and mesiotemporal cortices.

CONCLUSION(S)

Postsynaptic 5HT1A receptor binding is reduced in PD women by a similar magnitude as has been shown in other depression samples. The postpartum hormonal milieu and the large proportion of bipolar spectrum subjects in the PD group may have accentuated this finding in this small sample. Recognition of this neurobiological deficit in postpartum depression may be useful in the development of treatments and prevention strategies for this disabling disorder.

Capacity for 5-HT1A–mediated autoregulation predicts amygdala reactivity

We examined the contribution of 5-HT1A autoreceptors (with [11C]WAY100635 positron emission tomography) to amygdala reactivity (with blood oxygenation level-dependent functional magnetic resonance imaging) in 20 healthy adult volunteers. We found a significant inverse relationship wherein 5-HT1A autoreceptor density predicted a notable 30-44% of the variability in amygdala reactivity. Our data suggest a potential molecular mechanism by which a reduced capacity for negative feedback regulation of 5-HT release is associated with increased amygdala reactivity.

Postpartum depression: a randomized trial of sertraline versus nortriptyline

Symptom reduction and improvement in functioning in women with postpartum major depression treated with a tricyclic antidepressant versus a serotonin reuptake inhibitor were compared. The design was a double-blind, 8-week comparative trial of nortriptyline (NTP) versus sertraline (SERT) with a 16-week continuation phase. Women aged 18 to 45 years with postpartum major depression and a 17-item Hamilton Rating Scale for Depression score of 18 or more were eligible. Subjects were randomized to NTP or SERT and treated with a fixed-dosing strategy. Of 420 women interviewed, 109 eligible women received medication, and 95 provided follow-up data. The proportion of women who responded and remitted did not differ between drugs at 4, 8, or 24 weeks. Times to response and remission also did not differ. Psychosocial functioning improved similarly in both drug-treated groups of mothers. The total side effect burden of each drug was similar, although side effect profiles differed between agents. No clinical or demographic variables differentiated responders by drug. Women who were responders and remitters at week 8 could be identified earlier if they were treated with SERT than with NTP. Breast-fed infant serum levels were near or below the level of quantifiability for both agents.

Lesbian perinatal depression and the heterosexism that affects knowledge about this minority population

The medical literature about homosexuality and mental health is expanding; however, a paucity of research about lesbian mental health remains. No research about lesbian perinatal depression has been published. This paper highlights the heterosexism that perpetuates research and health care disparities between heterosexual and lesbian/gay/bisexual individuals. We acknowledge barriers that distance lesbian women from research and health care, and emphasize the importance of moving beyond these barriers to fill in gaps of knowledge about the specific health care needs of this minority population. We use an analysis of stress factors as a framework to generate hypotheses about perinatal depression in lesbian women. We conclude with suggestions for future study in the form of questions that should be asked and pursued in research.

Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications

CONTEXT

A neonatal behavioral syndrome linked to in utero serotonin reuptake inhibitor (SRI) exposure during the last trimester of pregnancy has been identified. The US Food and Drug Administration (FDA) and drug manufacturers have recently agreed to a class labeling change for SRIs, which include selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), to include information about potential adverse events in neonates exposed in utero. Integration of data about the neonatal behavioral syndrome into the management of pregnancy in women who take SRIs is a current challenge for physicians.

OBJECTIVES

To review evidence regarding the SRI-related neonatal syndrome and to help clinicians guide their patients in a risk-benefit decision-making process.

DATA SOURCES

We searched MEDLINE (1966-February 2005) and PsycINFO (1974-February 2005). All articles related to neonatal signs after in utero SRI exposure were acquired, as well as unpublished data on this topic from the FDA advisory committee meeting of June 2004. References cited in case reports and studies were reviewed. Foreign-language literature was included and translated to English.

STUDY SELECTION AND DATA EXTRACTION

Studies were included if they had clearly identified maternal SRI exposure for a minimum of the final trimester of pregnancy through delivery and assessed neonatal outcomes. We identified 13 case reports describing a total of 18 cases. Nine cohort studies met criteria. When not included in the published article, relative risks and 95% confidence intervals (CIs) were computed from raw data and summary risk ratios and 95% CIs were determined with Mantel-Haenszel estimates.

DATA SYNTHESIS

Compared with early gestational SRI exposure or no exposure, late SRI exposure carries an overall risk ratio of 3.0 (95% CI, 2.0-4.4) for a neonatal behavioral syndrome. The most SRI-related neonatal case reports involved fluoxetine and paroxetine exposures. Neonates primarily display central nervous system, motor, respiratory, and gastrointestinal signs that are usually mild and disappear by 2 weeks of age. Medical management has consisted primarily of supportive care in special care nurseries. A severe syndrome that consists of seizures, dehydration, excessive weight loss, hyperpyrexia, or intubation is rare in term infants (1/313 quantifiable cases). There have been no reported neonatal deaths attributable to neonatal SRI exposure.

CONCLUSIONS

Available evidence indicates that in utero exposure to SRIs during the last trimester through delivery may result in a self-limited neonatal behavioral syndrome that can be managed with supportive care. The risks and benefits of discontinuing an SRI during pregnancy need to be carefully weighed for each individual patient. Development and validation of assessment methods and clinical management strategies are critical to advancing this research.

Antepartum and postpartum depression: healthy mom, healthy baby

This article summarizes the epidemiology, clinical features, and treatment of antepartum and postpartum major depression. This summary will enable primary care clinicians to recognize and screen for perinatal mood disorders and to initiate the risk-benefit decision-making process used in treatment selection. This review will also help identify patient factors that warrant psychiatric consultation. We selected and reviewed studies of antepartum and postpartum depression of greatest utility to primary care clinicians. We developed a graphical algorithm that summarizes the steps needed for the care of postpartum depressed women. The prevalence of postpartum depression ranges from 10% to 15%, with screening rates of depressive symptoms as high as 35% in African American women. The prevalence of antepartum depression is as high as 26% among women in poor, urban communities. Maternal depression is associated with adverse effects on fetal and infant development. The challenge of diagnosing perinatal major depression can be addressed by assessing for persistent cognitive and affective symptoms and functional impairment. Effective treatments include interpersonal psychotherapy and selective serotonin reuptake inhibitors. The treatment of perinatal depression requires a unique informed consent process that is guided by a discussion of maternal preferences, the severity of maternal illness and recommended treatment, the risks of psychotropic exposure, and the risks of untreated mental illness. Rapid and effective mental health intervention in depressed expectant or new mothers not only restores maternal function, but can also prevent adverse infant neurobehavioral outcomes.

Widespread increases of cortical serotonin type 2A receptor availability after hormone therapy in euthymic postmenopausal women

OBJECTIVE

To use statistical parametric mapping to determine the extent of previously reported serotonin type 2A (5HT(2A)) receptor binding potential (BP) increases in postmenopausal women following hormone therapy.

DESIGN

Repeated measures positron emission tomography (PET) study.

SETTING

Academic research environment.

PATIENT(S)

Five healthy, postmenopausal women.

INTERVENTION(S)

Serial PET images of [(18)F]altanserin uptake were acquired to measure 5HT(2A) receptor BP at menopausal baseline, following estradiol (E(2)), and following combined E(2) + micronized progesterone (P(4)).

MAIN OUTCOME MEASURE(S)

5HT(2A) receptor BP.

RESULT(S)

Combined E(2) + P(4) treatment was associated with significant increases in the 5HT(2A) receptor BP increases in widespread areas of cerebral cortex. Treatment with E(2) alone was also associated with widespread cortical BP increases, although these changes reached statistical significance in fewer regions. The rate of [(18)F]altanserin metabolism was significantly decreased in the E(2) + P(4) condition relative to menopausal baseline, but this difference did not appear to correlate with changes in 5HT(2A) receptor BP.

CONCLUSION(S)

Estradiol priming followed by combined E(2) + P(4) is associated with widespread increases in 5HT(2A) receptor BP in the cerebral cortex, consistent with the E(2)-associated increases in 5HT(2A) receptor density previously observed in experimental animals.