Metformine for psychosis associated with the menstrual cycle in a patient with polycystic ovary syndrome

There are several reports of periodic psychotic disorders that appear in connection with the various phases of the menstrual cycle. Although the pathogenesis of menstrual psychosis has not been systematically investigated, it appears that it might be linked to an estrogen cascade that follows a period of sustained high estrogen levels, as in the case in anovulatory cycles. We present a case of psychosis associated with the menstrual cycle in a patient with polycystic ovary syndrome, a disorder typically characterized by anovulatory cycles, in whom the restoration of normal menstruation with use of metformine led to significant improvement of psychotic symptoms.

Antenatal psychosocial assessment for reducing perinatal mental health morbidity

BACKGROUND

Mental health conditions arising in the perinatal period, including depression, have the potential to impact negatively on not only the woman but also her partner, infant, and family. The capacity for routine, universal antenatal psychosocial assessment, and thus the potential for reduction of morbidity, is very significant.

OBJECTIVES

To evaluate the impact of antenatal psychosocial assessment on perinatal mental health morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, the Cochrane Depression, Anxiety and Neurosis Group's Trials Register (CCDAN TR-Studies), HSRProj in the National Library of Medicine (USA), and the Current Controlled Trials website: http://www.controlled trials.com/ and the UK National Research Register (last searched March 2008).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for eligibility; they also extracted data from included trials and assessed the trials for potential bias.

MAIN RESULTS

Two trials met criteria for an RCT of antenatal psychosocial assessment. One trial examined the impact of an antenatal tool (ALPHA) on clinician awareness of psychosocial risk, and the capacity of the antenatal ALPHA to predict women with elevated postnatal Edinburgh Depression Scale (EDS) scores, finding a trend towards increased clinician awareness of 'high level' psychosocial risk where the ALPHA intervention had been used (relative risk (RR) 4.61 95% confidence interval (CI) 0.99 to 21.39). No differences between groups were seen for numbers of women with antenatal EDS scores, a score of greater than 9 being identified by ALPHA as of concern for depression (RR 0.69 95% CI 0.35 to 1.38); 139 providers. The other trial reported no differences in EPS scores greater than 12 at 16 weeks postpartum between the intervention (communication about the EDS scores with the woman and her healthcare providers plus a patient information booklet) and the standard care groups (RR 0.86 95% CI 0.61 to 1.21; 371 women).

AUTHORS' CONCLUSIONS

While the use of an antenatal psychosocial assessment may increase the clinician's awareness of psychosocial risk, neither of these small studies provides sufficient evidence that routine antenatal psychosocial assessment by itself leads to improved perinatal mental health outcomes. Further studies with better sample size and statistical power are required to further explore this important public health issue. It will also be important to examine outcomes up to one year postpartum not only for mother, but also infant and family.

Perceived and observed mother-child interaction at time of hospitalization and release in postpartum depression and psychosis

INTRODUCTION

A pilot study was conducted which compared perceived mother-infant bonding in women admitted with postpartum depression or psychosis, with observations of mother-infant interaction by the nursing staff at both the time of hospitalization and that of release.

METHOD

25 mother-infant pairs admitted to a psychiatric unit were included in this study. The Postpartum Bonding Questionnaire was used to assess the perceived mother-infant bond and the observation of mother-infant interaction was assessed with the Bethlem Mother-Infant Interaction Scale.

RESULTS

At the time of both hospitalization and release postpartum depressed women experienced the bond with their child significantly more negative than women with postpartum psychosis. In contrast to women with postpartum psychosis, the experience of postpartum depressed women was significantly correlated with the observations of the nursing staff at time of release.

CONCLUSION

Treatment that focuses on a mother's experience of the bond with her child could be especially beneficial for mothers with postpartum depression.

Post-abortion and post-partum psychiatric hospitalization

Confusion persists regarding relative psychological risks associated with term deliveries and induced abortions. One reason for the scarcity of comparative findings is the lack of epidemiological data on post-abortion and post-partum admissions to psychiatric hospital. While such admissions are not separately tracked in United States health statistics, they are measurable events, reflective of severe psychological stress associated in time with delivery and abortion, and probably less subject to diverse interpretation than are individual consultations with clinical practitioners in their offices. The paper reviews what is known from published international research about post-abortion and post-partum admissions to psychiatric hospitals and discusses comparative findings obtained from computer linkages of Danish national registers. Admissions to psychiatric hospital were tracked for a three-month period after either delivery or abortion for all women under age 50 and then compared with the three-month admission rate to psychiatric hospitals for all Danish women of similar age. The major finding is that for never-married and currently married women, the post-pregnancy-related risk of admission is about the same-around 12 per 10 000 abortions or deliveries. Higher psychiatric admission rates were noted for separated, divorced and widowed women having abortions or carrying to term.

Tobacco use triggers for mothers of infants: implications for pediatric nursing practice

PURPOSE

To extend current knowledge of tobacco use by exploring whether subsets of mothers of infants have unique triggers for smoking relapse during the early stages of becoming a mother.

METHOD

Using data from a study of smoking relapse among mothers of infants (N = 133), comparative analyses were conducted for groups formed on the basis of their intention to be nonsmokers after delivery (yes/no) and their actual smoking behavior during the first 2 weeks of infant life (yes/no).

FINDINGS

The identified groups of mothers were found to be significantly different from one another in several ways, including self-reports that their baby's crying episodes caused them to think about smoking and their level of self-confidence to not smoke as response to infant crying.

CONCLUSIONS

Pediatric nurses in primary and acute care settings are in a unique position to support mothers for whom the challenge of handling infant cry episodes is a trigger for smoking behavior. Interventions that teach mothers how to cope with infant irritability are likely to support the smoking cessation efforts, and consequently, interrupt the intergenerational cycle of tobacco-related maternal and child health morbidities.

[Mortality in pregnant and newly delivered women due to psychiatric disorders]

Two women, aged 28 and 37 years, both suffering from a psychiatric disorder i.e. puerperal psychosis and mood-disorder respectively, violently ended their lives at 12 days and 5 months after delivery. Early identification of risk factors in a multidisciplinary setting can lead to effective early management of psychiatric disorders during pregnancy and the puerperium. Negative outcomes such as suicide and even infanticide may consequently be prevented. The most common risk factors for suicide during pregnancy and the puerperium are: a history of psychiatric disorders, a family history of psychiatric disorders and current psychiatric symptomatology. Important recommendations to reduce maternal mortality due to psychiatric disorders include improvement of communication between health professionals and systematic registration of maternal mortality.

Risk of depression and other mental health disorders in women with polycystic ovary syndrome: a longitudinal study

OBJECTIVE

To determine the conversion risk and predictors for depression in women with polycystic ovary syndrome.

DESIGN

Prospective longitudinal study.

SETTING

University practice.

PATIENT(S)

Subjects with polycystic ovary syndrome who had participated in a previous study.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire was used to diagnose major depressive disorder and other depressive syndromes, anxiety syndromes, and binge eating disorder. Subjects completed a questionnaire on knowledge about polycystic ovary syndrome and treatment satisfaction.

RESULT(S)

A total of 60 of 103 subjects responded to the second survey. Mean time between the two surveys was 22 months (range 12-26 months). The overall prevalence of depression was 40% (24/60). Of these, 10 women screened positive for major depressive disorder or other depressive syndromes and 14 were receiving antidepressant medications. There were 11 new cases identified in the second survey (19% conversion). Total subjects with mood disorders in this study were 34/60 (56.6%), including 11.6% with anxiety syndromes and 23.3% with binge eating disorder. Difficulties with menstrual function, fertility, and body image (weight, hirsutism, acne) were not significantly different in women with and without depression.

CONCLUSION(S)

There is a significant risk for mood disorders (defined by the Diagnostic and Statistical Manual of Mental Disorders-IV) in women with polycystic ovary syndrome. This finding together with a high conversion risk for depression over a 1- to 2-year period underscores the importance of routine screening and aggressive treatment of mental health disorders in this population.

Management of postpartum loss of libido

Following the birth of a child many physical, emotional and hormonal changes occur which can all have an impact. These include painful sex due to healing stitches or infection, low mood and depression and physiological changes due to breast-feeding or contraception. These can all affect the woman's sexual needs and impact on her relationship with her partner. Surveys of women postnatally suggest that there is an unmet need for discussing these issues and offering sensitive help and advice.

Porcine maternal infanticide as a model for puerperal psychosis

Childbirth is a period of substantial rapid biological and psychological change and a wide range of psychotic disorders can occur ranging from mild 'baby blues' to severe episodes of psychotic illnesses. Puerperal psychosis is the most extreme form of postnatal psychosis, occurring in 1 in 1,000 births. In this study, we have used the pig as an animal model for human postnatal psychiatric illness. Our aim was to identify quantitative trait loci (QTL) associated with maternal (infanticide) sow aggression. This is defined by sows attacking and killing their own newborn offspring, within 24 hr of birth. An affected sib pair whole genome linkage analysis was carried out with 80 microsatellite markers covering the 18 porcine autosomes and the X chromosome, with the aim of identifying chromosomal regions responsible for this abnormal behavior. Analysis was carried out using the non-parametric linkage test of Whittemore and Halpern, as implemented in the Merlin software. The results identified 4 QTL mapping on Sus scrofa chromosomes 2 (SSC2), 10 (SSC10), and X (SSCX). The peak regions of these QTL are syntenic to HSA 5q14.3-15, 1q32, Xpter-Xp2.1, and Xq2.4-Xqter, respectively. Several potential candidate genes lie in these regions in addition to relevant abnormal behavioral QTL, found in humans and rodents.

Rates of depressive and anxiety disorders in a residential mother-infant unit for unsettled infants

OBJECTIVE

Depression and anxiety are known to be common among women presenting to residential mother-infant programmes for unsettled infant behaviour but most studies have used self-report measures of psychological symptomatology rather than diagnostic interviews to determine psychiatric diagnoses. The aim of the present study was to determine rates of depressive and anxiety disorders and rates of comorbidity among clients of the Karitane residential mother-infant programme for unsettled infant behaviour.

METHOD

one hundred and sixty seven [corrected] women with infants aged 2 weeks-12 months completed the Edinburgh Postnatal Depression Scale and were interviewed for current and lifetime history of depressive and anxiety disorders using the Structured Clinical Interview for DSM-IV diagnosis (Research version).

RESULTS

A total of 25.1% of the sample met criteria for a current diagnosis of major depression, 31.7% had met criteria for major depression since the start of the pregnancy, and 30.5% of clients met criteria for a current anxiety disorder. Of note were the 21.6% who met criteria for generalized anxiety disorder or anxiety disorder not otherwise specified (worry confined to the topics of the baby or being a mother). High levels of comorbidity were confirmed in the finding that 60.8% of those with an anxiety disorder had experienced major or minor depression since the start of their pregnancy and 46.3% of those who had experienced depression since the start of their pregnancy also met criteria for a current anxiety disorder.

CONCLUSIONS

There are high levels of psychiatric morbidity among clients attending residential mother-infant units for unsettled infant behaviour, highlighting the importance of providing multifaceted interventions in order to address both infant and maternal psychological issues.

Thérapeutique des troubles anxieux et dépressifs de la grossesse et du post-partum. Revue et synthèse

The aim of this article is to review the main methods of treatment of anxious and depressive disorders during pregnancy and the postpartum. To this end, we analyse recent publications about the use and efficacy of psychotherapy and psychosocial interventions (cognitive behavioural therapy, interpersonal psychotherapy, psychoanalytical therapy) in the perinatal period. We also review recent papers about the use of psychotropic medication during pregnancy and breast-feeding, with special emphasis on clinical trials. We particularly focus on the risk/benefit assessment of antidepressants, mood stabilisers, antipsychotics and benzodiazepines, in terms of teratogenicity, and impact on neonatal adaptation and neuropsychological development. Various treatment modalities are presented and discussed. It appears that psychotherapies have proved their efficiency on most pre- and postpartum anxious and depressive disorders and represent a first line treatment in most cases. Psychopharmacological treatment is indicated for severe anxious and depressive disorders. The risks of such medication, especially antidepressants, may have been overestimated in the past. Provided reasonable precautions are taken and mothers and future mothers receive clear information on the potential risks and benefits, psychotropic medication could be more broadly prescribed during pregnancy and the breast-feeding period.

Cognitive behaviour therapy for postnatal post-traumatic stress disorder: case studies

Background. Approximately 1-2% of women suffer from postnatal post-traumatic stress disorder (PTSD) with wide ranging consequences for these women and their families 1. Appropriate treatment of women who have difficult or traumatic births is not yet established. Evidence in other populations shows that cognitive behavior therapy (CBT) is effective for PTSD and it is therefore the recommended treatment 2. However, a recent review of treatments for postnatal distress concluded that descriptions of postnatal counseling are largely generalized and non-specific, which makes them difficult to assess or replicate 3. Aims and method. The current paper therefore aims to describe the use of CBT interventions to treat postnatal distress, and to illustrate common themes or issues that occur in postnatal PTSD. This paper reports two case studies of women with postnatal PTSD and their treatment using CBT. Conclusions. In these cases, CBT was an effective treatment for postnatal PTSD. A number of implications are explored for the management of pregnancy and labor.

Postoperative Pain After Cesarean Birth Affects Breastfeeding and Infant Care

OBJECTIVE

To study women's experience of postoperative pain and pain relief after cesarean birth and factors associated with pain assessment and the birth experience.

DESIGN

Descriptive patient survey. Data were collected through a questionnaire. The outcome variables were assessments of pain using a Visual Analog Scale and women's birth experience measured on a seven-point Likert scale.

SETTING

Central Swedish county hospital, maternity unit.

PATIENTS/PARTICIPANTS

The sample consisted of 60 women undergoing cesarean birth.

RESULTS

Women reported high levels of experienced pain during the first 24 hours. Seventy-eight percent of the women scored greater than or equal to 4 on the Visual Analog Scale, which can be seen as inadequately treated pain. There was no difference between elective and emergency cesarean births in the levels of pain. In spite of high levels of pain, women were pleased with the pain relief. The risk of a negative birth experience was 80% higher for women undergoing an emergency cesarean birth compared with elective cesarean birth. Postoperative pain negatively affected breastfeeding and infant care.

CONCLUSIONS

There is a need for individual and adequate pain treatment for women undergoing cesarean birth, as high levels of pain interfere with early infant care and breastfeeding.

A Q methodology study of women's experience of enduring postnatal perineal and pelvic floor morbidity

OBJECTIVE

to explore women's experiences of enduring postnatal perineal and pelvic floor morbidity.

DESIGN

a retrospective Q methodology study of postnatal women between 12 and 18 months postpartum.

SETTING

maternity services at the Heart of England NHS Foundation Trust, Birmingham.

PARTICIPANTS

women were self-identified by expression of interest as part of their earlier involvement in a retrospective cross-sectional community survey of enduring postnatal perineal and pelvic floor morbidity. Twenty women responded to the invitation posted on the back of the initial survey questionnaire. All 20 women took part in stage one (interview) of the study (100% response rate). Fourteen women returned the completed response grids in stage four after 1 month of dissemination (response rate 70%).

METHODS

the project included five stages: (1) data were gathered using an individual face-to-face, semi-structured, community-based interview method (developing the concourse); (2) the concourse was analysed using MAXqda (2004) to produce 'themes'; (3) the themes were reduced to 'statements' that reflected the overall content of the concourse using an unstructured evolving approach to Q set design (giving the Q set); (4) participants were asked to sort the statements (Q sorting) according to a pre-designed distribution grid (providing individual participant response grids); and (5) the response grids were factor analysed using PQMethod (V2.0), which generates clusters of participants rather than clusters of variables. Factor loadings were calculated using factor analysis by principal components with varimax rotation. This produced a list of factors, each of which represents a 'story' of women's experience of enduring postnatal perineal and pelvic floor morbidity.

FINDINGS

five factors were identified: perineal morbidity of minor inconvenience, insufficient support and services, the 'taboo' subject of enduring perineal and pelvic floor morbidity, normalising morbidity and the isolation of perineal morbidity. Women varied in their experiences of enduring postnatal perineal and pelvic floor morbidity, with some having minor problems, with little affect on daily living, whereas others were significantly affected. The affect of the morbidity varied. Women highlighted the lack of service provision for these problems and stated that health-care practitioners, and society at large, were often dismissive of, or trivialised, their experiences of enduring postnatal perineal and pelvic floor morbidity.

CONCLUSION

the findings from this study highlight that the postnatal recovery period is longer than the presumed 6 weeks. The effect of postnatal perineal and pelvic floor morbidity on women's lives varies, and more long-term postnatal health support and research using women-centred outcomes is needed.

Identifying risk factors for postpartum tobacco use

PURPOSE

To identify factors associated with becoming a mother that may contribute to postpartum smoking-related outcomes.

DESIGN

Cross-sectional, correlational.

METHODS

Postpartum women (N=133) who were clients in a nutrition supplement program for low-income families responded to questionnaires about smoking and early motherhood experiences. Inferential statistical tests included hierarchical multiple and logistic regression.

FINDINGS

After controlling for factors known to be associated with smoking outcomes for the general population, factors associated with becoming a mother significantly contributed to the amount of explained variance in both postpartum self-efficacy to refrain from smoking and smoking within 2 weeks after delivery.

CONCLUSIONS

Study findings indicated that prenatal intentions about postpartum tobacco use and maternal response to infant cry episodes were areas for risk assessment that might lead to effective smoking cessation interventions uniquely tailored to women who experience becoming a mother.

Postpartum anxiety and breast feeding

OBJECTIVE

To evaluate the relationship between postpartum anxiety and lactation experience, knowledge, confidence and performance.

STUDY DESIGN

State anxiety was measured among breast-feeding women by the State Trait Anxiety Inventory before hospital discharge and at 1 month postpartum. Breast-feeding experience and knowledge were assessed by focused questions and confidence by the Breastfeeding Confidence Scale. Breast-feeding performance measures included breast-feeding immediately after delivery; formula supplementation in the hospital; full, exclusive breast-feeding; and breast-feeding termination at 1 month postpartum.

RESULTS

Predischarge anxiety correlated inversely with breast-feeding confidence (r [339] = -0.27, p = 0.000) but not with experience or knowledge. As compared to low-anxiety mothers, those with high anxiety were less likely to breast-feed after delivery (53.0% vs. 65.1%, p = 0.049) and more likely to give their infants formula (43.9% vs. 29.1%, p = 0.022). In logistic regression models adjusting for demographic and social factors, high-anxiety mothers were less likely to practice full, exclusive breast-feeding (AOR = 0.39; 95% CI 0.20, 0.74; p < 0.005) and more likely to have terminated breastfeeding at 1 month (AOR = 4.40; 95% CI 1.70, 11.33; p < 0.005).

CONCLUSION

Postpartum anxiety may be associated with reduced breast-feeding confidence and lactation performance. Awareness of this association may be helpful in identifying women at risk for lactation failure and targeting efforts to promote breast-feeding.

[Clinical approach and epidemiological aspects of mood and anxiety disorders during pregnancy and postpartum. Review and synthesis]

The aim of this article is to review clinical and epidemiological data on pre- and postnatal anxious and depressive disorders. To this end, we systematically analysed definitions, prevalence, risk factors and obstetrical consequences of perinatal disorders, as reported in seminal as well as more recent publications. We report and discuss the most consensual results about anxious and depressive disorders of pregnancy and the postpartum, with special emphasis on maternity blues, postpartum depression and postpartum psychosis. Reviewed data confirm that the perinatal period is a time of high risk for the onset or exacerbation of several anxious or depressive disorders, which are likely to impede the normal progress of pregnancy or the child's development. The potential severity of bipolar disorders and puerperal psychosis is highlighted by the fact that they heavily contribute to maternal mortality. The specificity of perinatal disorders, their impact on public health, the extensive research and mounting knowledge in that field, provide ample justification for the recognition of perinatal psychiatry as a distinct branch of psychiatry.

Risk factors for poor self-rated health in women at 2 months and 1 year after childbirth

OBJECTIVE

To investigate risk factors for poor self-rated health (SRH) in primiparous and multiparous women 2 months and 1 year after childbirth in a nationwide Swedish sample.

METHODS

Women were recruited at their first booking visit at 593 (97%) antenatal clinics in Sweden during 3 weeks evenly spread over 1 year (1999-2000). Data were collected by questionnaires in early pregnancy, 2 months and 1 year after childbirth, and from the Medical Birth Register. In total, 2424 women filled in all the questionnaires, including a global question on SRH. The representativity of the sample was assessed by comparison with the total Swedish birth cohort of 1999. Data were analyzed by logistic regression analysis.

RESULTS

Physical problems, such as tiredness, musculoskeletal symptoms, and abdominal pain, and emotional problems, such as depressive symptoms, increased the risk of poor SRH in both primiparas and multiparas at one or both time points. Infant-related risk factors in both groups were negative experience of breastfeeding (2 months) and infant sleeping problems (1 year), and prematurity was a risk factor in primiparas at 2 months. Insufficient social support increased the risk in multiparas. In primiparas, outcome of labor, such as negative birth experience after operative delivery, was associated with poor SRH at 1 year and perineal pain at 2 months.

CONCLUSIONS

A new mother's SRH is associated with her life situation. Ongoing physical and emotional problems, lack of support, and infant factors seem more important than sociodemographic background. Mode of delivery and childbirth experience may have a longterm effect on SRH.