Self-Reported Alcohol, Tobacco, and Marijuana Use in Pregnant Women with Depressive Symptomatology

OBJECTIVE

Substance use disorders often coexist with depression. The objective of this study was to establish whether pregnant women who report depressive symptomatology were more likely to report use of alcohol, tobacco, and marijuana during pregnancy.

STUDY DESIGN

This was a secondary analysis of prospectively collected data from the Maternal-Fetal Medicine Units Network Preterm Prediction Study. Self-reported history of alcohol, tobacco, and marijuana use was compared between pregnant women with and without depressive symptomatology with adjustment for demographic factors.

RESULTS

After adjustment for demographic factors, women with depressive symptomatology were more likely to report: any alcohol use (odds ratio [OR]: 1.4, 95% confidence interval [CI]: 1.1-1.8), >1 drink per week (OR: 1.3, 95% CI: 1.0-1.8), and >1 drink per day (OR: 2.2, 95% CI: 1.5-3.4). Women with depressive symptomatology were also more likely to report use of marijuana (OR: 1.8, 95% CI: 1.2-2.6) and cigarettes (OR: 1.4, 95% CI: 1.1-1.7).

CONCLUSION

Depressive symptomatology was associated with an increase in self-reported the use of alcohol, tobacco, and marijuana during pregnancy. These data reveal the importance of targeted screening of pregnant women with depressive symptomatology for substance use.

Maternal choline and respiratory coronavirus effects on fetal brain development

Prenatal COVID-19 infection is anticipated by the U.S. Centers for Disease Control to affect fetal development similarly to other common respiratory coronaviruses through effects of the maternal inflammatory response on the fetus and placenta. Plasma choline levels were measured at 16 weeks gestation in 43 mothers who had contracted common respiratory viruses during the first 6-16 weeks of pregnancy and 53 mothers who had not. When their infants reached 3 months of age, mothers completed the Infant Behavior Questionnaire-Revised (IBQ-R), which assesses their infants' level of activity (Surgency), their fearfulness and sadness (Negativity), and their ability to maintain attention and bond to their parents and caretakers (Regulation). Infants of mothers who had contracted a moderately severe respiratory virus infection and had higher gestational choline serum levels (≥7.5 mM consistent with U.S. Food and Drug Administration dietary recommendations) had significantly increased development of their ability to maintain attention and to bond with their parents (Regulation), compared to infants whose mothers had contracted an infection but had lower choline levels (<7.5 mM). For infants of mothers with choline levels ≥7.5 μM, there was no effect of viral infection on infant IBQ-R Regulation, compared to infants of mothers who were not infected. Higher choline levels obtained through diet or supplements may protect fetal development and support infant early behavioral development even if the mother contracts a viral infection in early gestation when the brain is first being formed.

Maternal Prenatal Depression in Pregnancies With Female and Male Fetuses and Developmental Associations With C-reactive Protein and Cortisol

BACKGROUND

Prenatal depression has lasting effects on development in offspring, including later mental illness risk. Maternal responses to depression include inflammation and hypothalamic-pituitary-adrenal axis stimulation. Effects on development of cerebral inhibitory neurocircuits may differ for female and male fetuses.

METHODS

Mothers (N = 181) were assessed periodically, beginning at 16 weeks' gestation, using the Center for Epidemiologic Studies-Depression Scale. Maternal prenatal C-reactive protein and hair cortisol and cortisone levels were determined. Cortisone was determined in neonatal hair. Development of cerebral inhibitory neurocircuits was assessed in 162 1-month-old newborns by inhibition of P50 electrophysiological responses to repeated sounds.

RESULTS

Maternal depression was associated with decreased newborn P50 inhibition in both sexes. Maternal C-reactive protein levels were significantly associated with depression only in pregnancies with male fetuses and with decreased newborn P50 inhibition only in male newborns. Maternal cortisol levels were significantly associated with depression only in pregnancies with female fetuses and with decreased newborn P50 inhibition only in female newborns. In pregnancies with male fetuses compared with pregnancies with female fetuses, cortisol was more robustly metabolized to cortisone, which does not activate cortisol receptors.

CONCLUSIONS

This study finds sex-specific associations of C-reactive protein and cortisol levels with prenatal depression in women and with decreased development of newborn P50 inhibition. Sex-based differences in maternal response to depression with inflammation or cortisol and their developmental effects may reflect evolutionary influences to promote survival in adversity. Decreased newborn P50 inhibition is associated with later childhood behavioral problems, and decreased P50 inhibition is a pathophysiological feature of several mental illnesses.

Maternal and child delivery charges, postpartum charges, and utilization of care among women with bipolar disorder: a cohort study

Bipolar disorder (BD) during pregnancy is known to be a morbid condition associated with poor outcomes for both the mother and her infant. We aimed to determine if women with BD and their children have higher charges and health service utilization than mother-infant dyads with and without other mental health (MH) diagnoses. The International Classification of Diseases, Ninth Revision (ICD9) codes were used to identify mutually exclusive groups of women who gave birth between January 1, 2011, and December 31, 2012, coding first for BD, then diagnoses that comprised an "other MH diagnoses group" that included post-traumatic stress disorder, anxiety, and depression. Health service utilization and related charges were obtained for the dyad for delivery and for 2 years post-delivery at a single tertiary care center. Analyses included 4440 dyads. A BD diagnosis occurred in 1.8% of medical record codes, other MH diagnoses in 10%, and no known MH diagnosis in 88%. Compared with women with both other MH and no known MH diagnoses, women with BD had higher delivery charges (p < 0.001), higher cumulative charges in the 2 years postpartum (p < 0.001), higher preterm birth and low birthweight rates (15.5% v. 6.9% and 20.8% v. 6.4%, p < 0.001, BD v. no known MH, respectively), and greater utilization of inpatient and emergency psychiatric care services (p < 0.001). Compared with women with and without other mental health diagnoses, women with BD have the highest care utilization and charges. They also have higher preterm birth and low birthweight infant rates, two clinically relevant predictors of long-term health for the child. Given the low prevalence of BD and severity of the disease versus the magnitude of systems costs, women with BD, and their children, deserve the heightened attention afforded to other high-risk perinatal conditions.

Interaction of maternal choline levels and prenatal Marijuana's effects on the offspring

BACKGROUND

This study investigated whether higher maternal choline levels mitigate effects of marijuana on fetal brain development. Choline transported into the amniotic fluid from the mother activates α7-nicotinic acetylcholine receptors on fetal cerebro-cortical inhibitory neurons, whose development is impeded by cannabis blockade of their cannabinoid-1(CB1) receptors.

METHODS

Marijuana use was assessed during pregnancy from women who later brought their newborns for study. Mothers were informed about choline and other nutrients, but not specifically for marijuana use. Maternal serum choline was measured at 16 weeks gestation.

RESULTS

Marijuana use for the first 10 weeks gestation or more by 15% of mothers decreased newborns' inhibition of evoked potentials to repeated sounds (d' = 0.55, p < 0.05). This effect was ameliorated if women had higher gestational choline (rs = -0.50, p = 0.011). At 3 months of age, children whose mothers continued marijuana use through their 10th gestational week or more had poorer self-regulation (d' = -0.79, p < 0.05). This effect was also ameliorated if mothers had higher gestational choline (rs = 0.54, p = 0.013). Maternal choline levels correlated with the children's improved duration of attention, cuddliness, and bonding with parents.

CONCLUSIONS

Prenatal marijuana use adversely affects fetal brain development and subsequent behavioral self-regulation, a precursor to later, more serious problems in childhood. Stopping marijuana use before 10 weeks gestational age prevented these effects. Many mothers refuse to cease use because of familiarity with marijuana and belief in its safety. Higher maternal choline mitigates some of marijuana's adverse effects on the fetus.

Pushing beyond the silos: the obstetrician's role in perinatal depression care

Perinatal depression is one of the most common medical complications during and after pregnancy, occurring in up to 20% of new mothers in the USA. It can have both short- and long-term effects on the mother, child, and family. Multiple etiologies have been proposed for perinatal depression, and there are many reported genetic, epigenetic, environmental, socioeconomic, and psychosocial risk factors. Perinatal depression can be treatable but remains underdiagnosed and undertreated for a variety of reasons, including inconsistent clinical definitions, inconsistent screening, social stigma, and logistic/financial barriers to evidence-based treatments. The diagnosis and treatment of perinatal depression can be complicated by the frequent need for coordination among multiple care providers before and after childbirth. Among the care providers who may encounter perinatal depression, obstetricians are uniquely positioned to provide anticipatory guidance at regular prenatal visits and to identify symptoms and coordinate care, as they follow patients at multiple encounters throughout pregnancy and into the postpartum period. While obstetricians are already among the most common healthcare professionals who diagnose and treat perinatal depression, an opportunity for obstetricians to enhance early detection and treatment of perinatal depression exists. Professional societies and patient advocacy organizations support implementation of universal screening during the perinatal period, and validated clinical tools can detect nearly 50% more patients than more informal methods. This review outlines our current knowledge of perinatal depression and highlights the vital role of obstetricians in screening and treatment.

Maternal self-harm deaths: an unrecognized and preventable outcome

Maternal mortality continues to be a public health priority in national and international communities. Maternal death rates secondary to medical illnesses such as cardiovascular disease, preeclampsia, and postpartum hemorrhage are well documented. The rates of maternal death secondary to self-harm, including suicide and overdose, have been omitted from published rates of maternal mortality, despite growing attention to the prevalence of perinatal mood disorders, estimated at up to 15% of pregnant and postpartum women in the United States. Underlying psychiatric disorder, including depression, is consistently identified as a risk factor in substance abuse and suicide. The rate of opioid-associated morbidity and mortality has recently been deemed a national crisis. Pregnancy does not protect against these risks, and the postpartum period has been identified as a particularly vulnerable time. The lack of consistent and inclusive data on self-harm deaths in the pregnancy-postpartum period is alarming. This review will identify barriers to reporting and ascertainment of maternal suicide and overdose deaths, summarize geographic-specific data available, address potential social and psychological biases that have led to neglect of the topic of maternal self-harm deaths, and suggest recommendations that incorporate the whole woman in prenatal care and thus prevention of this devastating outcome.

Effects of phosphatidylcholine and betaine supplements on women's serum choline

Background

Maternal phosphatidylcholine supplements have shown benefit in the development of the human fetal brain, as assessed both by newborn physiological measurements and by a related decrease in later childhood behavioral abnormalities. However, the relatively low choline component of phosphatidylcholine mandates high doses that are difficult for pregnant women to consume.

Objective

Betaine can substitute for some choline effects. The hypothesis was that betaine supplementation would significantly increase women's serum choline.

Design

A three-arm crossover clinical trial was used to assess serum concentrations of choline after betaine supplements at two doses, in comparison with phosphatidylcholine supplementation. The effects of both a single dose and of one-week twice-daily doses were assessed in normal non-pregnant women.

Results

Betaine supplements at two doses failed to increase serum choline concentrations after single administration or one-week twice-daily dosing. Phosphatidylcholine supplements raised choline concentrations after both single doses (mean change from baseline 8.34 ± 7.29 ng/ml, paired t = 3.24, df 7, p = 0.014, range 1-21 ng/ml, d' = 1.15) and one-week twice-daily doses (mean change from baseline 4.58 ± 3.68 ng/ml standard deviation; paired t = 3.51, df 7, p < 0.001, range 2-13 ng/ml, d' = 2.65). Betaine concentrations rose after both betaine and phosphatidylcholine supplementation.

Conclusions

Betaine supplements did not substitute for phosphatidylcholine supplements, which raise serum choline concentrations both after a single dose and after repeated administration. However, serum betaine concentrations did rise after both betaine and phosphatidylcholine consumption and, therefore, betaine may be a stable indicator of choline intake.

Higher Gestational Choline Levels in Maternal Infection Are Protective for Infant Brain Development

OBJECTIVE

To assess whether maternal choline decreases effects of mothers' infections on fetal brain circuit development and on expression of infant behavior at 1 year of age.

STUDY DESIGN

A cross-sectional study was conducted in a public hospital obstetrics and midwifery service, with prenatal assessments of maternal infection, C-reactive protein, and choline level and postnatal assessments of cerebral neuronal inhibition in 162 newborns. At 1 year, 136 parents completed reports of their child's behavior.

RESULTS

Maternal infection at 16 weeks of gestation, experienced by 41% of mothers, raised mean maternal C-reactive protein (d' = 0.47, P = .002) and decreased the development of cerebral inhibition of auditory response at 1 month of age (d' = 0.39, P < .001). Decreased newborn cerebral inhibition manifested as decreased behavioral self-regulation at 1 year. Greater choline levels in mothers with infections were associated with improved newborn inhibition of auditory cerebral response, mitigating the effect of infection (β = -0.34 [95% CI, -5.35 to -0.14], P = .002). At 1 year of age, children of mothers with infection and greater gestational choline levels had improved development of self-regulation, approaching the level of children of mothers without infection (β = 0.29 [95% CI 0.05-0.54], P = .03).

CONCLUSIONS

Greater maternal choline, recommended by the American Medical Association as a prenatal supplement, is associated with greater self-regulation among infants who experienced common maternal infections during gestation. Behavioral problems with diminished self-regulation often lead to referrals to pediatricians and might lead to later mental illness.

Prenatal Primary Prevention of Mental Illness by Micronutrient Supplements in Pregnancy

Genes, infection, malnutrition, and other factors affecting fetal brain development are a major component of risk for a child's emotional development and later mental illnesses, including schizophrenia, bipolar disorder, and autism. Prenatal interventions to ameliorate that risk have yet to be established for clinical use. A systematic review of prenatal nutrients and childhood emotional development and later mental illness was performed. Randomized trials of folic acid, phosphatidylcholine, and omega-3 fatty acid supplements assess effects of doses beyond those adequate to remedy deficiencies to promote normal fetal development despite genetic and environmental risks. Folic acid to prevent neural tube defects is an example. Vitamins A and D are currently recommended at maximum levels, but women's incomplete compliance permits observational studies of their effects. Folic acid and phosphatidylcholine supplements have shown evidence for improving childhood emotional development associated with later mental illnesses. Vitamins A and D decreased the risk for schizophrenia and autism in retrospective observations. Omega-3 fatty acid supplementation during early pregnancy increased the risk for schizophrenia and increased symptoms of attention deficit hyperactivity disorder, but in later pregnancy it decreased childhood wheezing and premature birth. Studies are complicated by the length of time between birth and the emergence of mental illnesses like schizophrenia, compared with anomalies like facial clefts identified at birth. As part of comprehensive maternal and fetal care, prenatal nutrient interventions should be further considered as uniquely effective first steps in decreasing risk for future psychiatric and other illnesses in newborn children. [AJP at 175: Remembering Our Past As We Envision Our Future July 1959: Longitudinal Observations of Biological Deviations in a Schizophrenic Infant Barbara Fish described the course of an infant born with fluctuating motor problems who developed schizophrenia. (Am J Psychiatry 1959; 116:25-31 )].

Integrated perinatal mental health care: a national model of perinatal primary care in vulnerable populations

INTRODUCTION

Perinatal mood and anxiety disorders (PMADs) are the most common complication of pregnancy and have been found to have long-term implications for both mother and child. In vulnerable patient populations such as those served at Denver Health, a federally qualified health center the prevalence of PMADs is nearly double the nationally reported rate of 15-20%. Nearly 17% of women will be diagnosed with major depression at some point in their lives and those numbers are twice as high in women who live in poverty. Women also appear to be at higher risk for depression in the child-bearing years. In order to better address these issues, an Integrated Perinatal Mental Health program was created to screen, assess, and treat PMADs in alignment with national recommendations to improve maternal-child health and wellness. This program was built upon a national model of Integrated Behavioral Health already in place at Denver Health.

METHODS

A multidisciplinary team of physicians, behavioral health providers, public health, and administrators was assembled at Denver Health, an integrated hospital and community health care system that serves as the safety net hospital to the city and county of Denver, CO. This team was brought together to create a universal screen-to-treat process for PMAD's in perinatal clinics and to adapt the existing Integrated Behavioral Health (IBH) model into a program better suited to the health system's obstetric population. Universal prenatal and postnatal depression screening was implemented at the obstetric intake visit, a third trimester prenatal care visit, and at the postpartum visit across the clinical system. At the same time, IBH services were implemented across our health system's perinatal care system in a stepwise fashion. This included our women's care clinics as well as the family medicine and pediatric clinics. These efforts occurred in tandem to support all patients and staff enabling a specially trained behavioral health provider (psychologists and L.C.S.W.'s) to respond immediately to any positive screen during or after pregnancy.

RESULTS

In August 2014 behavioral health providers were integrated into the women's care clinics. In January 2015 universal screening for PMADs was implemented throughout the perinatal care system. Screening has improved from 0% of women screened at the obstetric care intake visit in August 2014 to >75% of women screened in August 2016. IBH coverage by a licensed psychologist or licensed clinical social worker exists in 100% of perinatal clinics as of January 2016. As well, in order to gain sustainability, the ability to bill same day visits as well as to bill, and be reimbursed for screening and assessment visits, continues to improve and provide for a model that is self-sustaining for the future.

CONCLUSION

Implementation of a universal screening process for PMADs alongside the development of an IBH model in perinatal care has led to the creation of a program that is feasible and has the capacity to serve as a national model for improving perinatal mental health in vulnerable populations.

Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety

Perinatal mood and anxiety disorders are among the most common mental health conditions encountered by women of reproductive age. When left untreated, perinatal mood and anxiety disorders can have profound adverse effects on women and their children, ranging from increased risk of poor adherence to medical care, exacerbation of medical conditions, loss of interpersonal and financial resources, smoking and substance use, suicide, and infanticide. Perinatal mood and anxiety disorders are associated with increased risks of maternal and infant mortality and morbidity and are recognized as a significant patient safety issue. In 2015, the Council on Patient Safety in Women's Health Care convened an interdisciplinary work group to develop an evidence-based patient safety bundle to address maternal mental health. The focus of this bundle is perinatal mood and anxiety disorders. The bundle is modeled after other bundles released by the Council on Patient Safety in Women's Health Care and provides broad direction for incorporating perinatal mood and anxiety disorder screening, intervention, referral, and follow-up into maternity care practice across health care settings. This commentary provides information to assist with bundle implementation.

Perspectives from Patients and Healthcare Providers on the Practice of Maternal Placentophagy

PURPOSE

Placentophagy (maternal consumption of the placenta) has become increasingly prevalent in the past decade among women seeking to promote health and healing during the postpartum period. The purpose of this study was to assess patient and provider familiarity with and attitudes toward placentophagy, as well as patients' willingness to try placentophagy.

METHODS

Two cross-sectional surveys with questions regarding placentophagy practice were distributed to healthcare providers and patients. The provider survey was distributed via email listservers to international perinatal professional organizations and to obstetrics and gynecology, nurse midwifery, family medicine, and psychiatry departments at three urban hospitals. Patient surveys were administered in person at an urban hospital in Chicago, Illinois.

RESULTS

Approximately two thirds (66%; n = 100) of patients and most (89%; n = 161) of providers were familiar with placentophagy. Patients with a history of a self-reported mental health disorder were more likely to be willing to consider placentophagy and to believe that healthcare providers should discuss it with their patients.

CONCLUSIONS

Most providers and patients have heard of placentophagy but are unsure of its benefits and/or risks. Further research examining the potential therapeutic efficacy and/or risks of placentophagy is needed.

Cortisol during human fetal life: Characterization of a method for processing small quantities of newborn hair from 26 to 42 weeks gestation

OBJECTIVE

Fetal cortisol may be reflected in hair collected shortly after birth. The objective of this study was to determine the range of human fetal hair cortisol concentrations (HCC) in live-born neonates using an approach for processing small quantities of hair.

MATERIALS AND METHODS

Hair was cut on the day of birth from neonates and their mothers, born between 26 and 42 weeks gestational age (GA). HCC was determined by enzyme immunoassay. Maternal sociodemographics and birth data were collected. T-tests, ANOVA, Pearson correlation, and Wilcoxon Signed Rank test were used as appropriate.

RESULTS

Ninety maternal and neonatal hair samples were cut from 79 term (T) and 11 preterm (PT) delivered pregnancies. All samples weighed ≥2.5 mg. Fetal HCC correlated with GA (r = .25, p = .02) and birth weight (r = .25, p = .03) and was lower in PT (4.3 ± .3 LN pg/mg) than T (5.3 ± .1, LN pg/mg, p < .001) neonates. No significant relationships were seen between fetal HCC and maternal characteristics or maternal HCC. Fetal HCC was significantly higher than maternal HCC.

CONCLUSION

Fetal cortisol exposure was determined using this approach for processing small amounts of hair. Preterm neonates have significantly lower HCC than term neonates and fetal HCC is associated with GA at delivery and birth weight. Fetal HCC is significantly higher than maternal HCC cut on the same day. These data provide novel information on the intrauterine fetal cortisol environment.

Perinatal Phosphatidylcholine Supplementation and Early Childhood Behavior Problems: Evidence for CHRNA7 Moderation

OBJECTIVE

α7-Nicotinic receptors are involved in the final maturation of GABA inhibitory synapses before birth. Choline at levels found in the amniotic fluid is an agonist at α7-nicotinic receptors. The authors conducted a double-blind placebo-controlled trial to assess whether high-dose oral phosphatidylcholine supplementation during pregnancy to increase maternal amniotic fluid choline levels would enhance fetal development of cerebral inhibition and, as a result, decrease childhood behavior problems associated with later mental illness.

METHOD

The authors previously reported that newborns in the phosphatidylcholine treatment group have increased suppression of the cerebral evoked response to repeated auditory stimuli. In this follow-up, they report parental assessments of the children's behavior at 40 months of age, using the Child Behavior Checklist.

RESULTS

At 40 months, parent ratings of children in the phosphatidylcholine group (N=23) indicated fewer attention problems and less social withdrawal compared with the placebo group (N=26). The improvement is comparable in magnitude to similar deficits at this age associated with later schizophrenia. The children's behavior is moderated by CHRNA7 variants associated with later mental illness and is related to their enhanced cerebral inhibition as newborns.

CONCLUSIONS

CHRNA7, the α7-nicotinic acetylcholine receptor gene, has been associated with schizophrenia, autism, and attention deficit hyperactivity disorder. Maternal phosphatidylcholine treatment may, by increasing activation of the α7-nicotinic acetylcholine receptor, alter the development of behavior problems in early childhood that can presage later mental illness.

Group prenatal care for women with gestational diabetes (.)

OBJECTIVE

We aimed to determine if group prenatal care affects the progression to A2 gestational diabetes mellitus (GDM) when compared with conventional care for women with GDM.

METHODS

Prospective observational cohort of women diagnosed with GDM who attended group visits compared with a historical control group of women who received conventional obstetrical care in the year prior but would have met inclusion criteria for group care. The primary outcome was progression to A2 GDM. Secondary outcomes included antepartum, intrapartum and postpartum maternal outcomes and neonatal outcomes.

RESULTS

A total of 165 subjects were included: 62 in group care and 103 in conventional care. Compared with patients with conventional care, group subjects were more likely to attend a postpartum visit (92% versus 66%; p = 0.002) and were almost 4 times more likely to receive recommended diabetes screening postpartum (OR 3.9, CI 1.8-8.6). Group subjects were much less likely to progress to A2 GDM (OR 0.15, CI 0.07-0.30). There were no differences in neonatal outcomes.

CONCLUSIONS

Group prenatal care for women with diabetes is associated with decreased progression to A2 GDM and improved postpartum follow-up for appropriate diabetes screening without significantly affecting obstetrical or neonatal outcomes.

Chemical processing and shampooing impact cortisol measured in human hair

PURPOSE

The assessment of cortisol in hair has gained popularity as a means to measure retrospective hypothalamic-pituitary-adrenal activity in a number of species; however, cortisol levels from human hair subjected to typical chemicals for cosmetic or hygienic purposes may be altered by the chemicals used. The purposed of this study was to determine if exposure of hair to chemical processing or shampooing impacts cortisol values.

METHODS

Human hair not exposed to prior chemical processing was cut from the posterior vertex region of the head of 106 human subjects as close to the scalp as possible. The hair sample was divided into 4-6 full-length clusters depending on quantity of hair available. Each hair sample was processed for baseline (native) cortisol and remaining clusters were exposed to five standard chemical hair treatments (Experiment 1) or were shampooed 15 or 30 times (Experiment 2). Hair was ground and cortisol levels were determined by enzyme immunoassay (EIA). Comparisons were made between native hair and processed hair using paired t-tests and Pearson correlation.

RESULTS

Hair cortisol as assessed by EIA was significantly altered by chemical processing but in somewhat different ways. Exposure to bleach (harshest exposure), demi-perm (least exposure) or 15-30 shampoos resulted in a significant decrease in cortisol level while exposure to varying percentages of peroxides increased cortisol measured. There were no differences in cortisol levels associated with sex, age or tobacco use in the native hair for this particular group.

CONCLUSION

Chemical processing and frequent shampooing affect cortisol levels measured in hair. Chemically processed or excessively shampooed hair should be avoided when recruiting subjects for hair cortisol studies.