PTSD SYMPTOMS ACROSS PREGNANCY AND EARLY POSTPARTUM AMONG WOMEN WITH LIFETIME PTSD DIAGNOSIS

Treatment of depression, anxiety, and trauma-related disorders during the perinatal period: A systematic review

Women with psychiatric disorders during pregnancy and the postpartum period (i.e., perinatal period) are at increased risk for adverse maternal and child outcomes. Effective treatment of psychiatric disorders during the perinatal period is imperative. This review summarizes the outcomes of 78 studies focused on the treatment of depression, anxiety, and trauma-related disorders during the perinatal period. The majority of studies focused on perinatal depression (n = 73). Of the five studies focused on anxiety or trauma-related disorders, only one was a randomized controlled trial (RCT). The most studied treatment was cognitive behavioral therapy (CBT; n = 22), followed by interpersonal psychotherapy (IPT; n = 13). Other interventions reviewed include other talk therapies (n = 5), collaborative care models (n = 2), complementary and alternative medicine approaches (n = 18), light therapy (n = 3), brain stimulation (n = 2), and psychopharmacological interventions (n = 13). Eleven studies focused specifically on treatment for low-income and/or minority women. Both CBT and IPT demonstrated a significant benefit over control conditions. However, findings were mixed when these interventions were examined in low-income and/or minority samples. There is some support for complementary and alternative medicine approaches (e.g., exercise). Although scarce, SSRIs demonstrated good efficacy when compared to a placebo. However, SSRIs did not outperform another active treatment condition (e.g., CBT). There is a tremendous need for more studies focused on treatment of perinatal anxiety and trauma-related disorders, as well as psychopharmacological effectiveness studies. Limitations and future directions of perinatal treatment research, particularly among low-income and/or minority populations, are discussed.

Postpartum outcomes of a pilot prenatal care-based psychosocial intervention for PTSD during pregnancy

This study examines postpartum posttraumatic stress disorder (PTSD) symptoms and secondary outcomes including postpartum depression and birth outcomes for pregnant women who screened positive for PTSD and received a psychosocial education intervention compared to women with PTSD in the usual prenatal care setting. All women entering prenatal care at two federally qualified health centers were screened for symptoms of current PTSD; one site was selected randomly to have prenatal care advocates deliver eight Seeking Safety topics for women with clinical or subclinical PTSD. Women were not blind to condition. Baseline and postpartum interviews, including demographic characteristics and assessment of mental health, social support, and coping skills, were conducted. Medical record data was collected to document preterm delivery and low birth weight. Of the 149 participants at baseline, 128 (86%) participated in the postpartum interview. Intervention women, compared to controls, significantly decreased PTSD symptoms, and showed a non-significant trend for improved social support. However, depression, coping, and birth outcomes did not differ. This study suggests some initial support for the Seeking Safety intervention in prenatal care settings and requires further research to determine the best approaches to its implementation.

Postpartum psychiatric disorders

Pregnancy is a complex and vulnerable period that presents a number of challenges to women, including the development of postpartum psychiatric disorders (PPDs). These disorders can include postpartum depression and anxiety, which are relatively common, and the rare but more severe postpartum psychosis. In addition, other PPDs can include obsessive-compulsive disorder, post-traumatic stress disorder and eating disorders. The aetiology of PPDs is a complex interaction of psychological, social and biological factors, in addition to genetic and environmental factors. The goals of treating postpartum mental illness are reducing maternal symptoms and supporting maternal-child and family functioning. Women and their families should receive psychoeducation about the illness, including evidence-based discussions about the risks and benefits of each treatment option. Developing effective strategies in global settings that allow the delivery of targeted therapies to women with different clinical phenotypes and severities of PPDs is essential.

Trajectories of traumatic stress symptoms during conflict: A latent class growth analysis

BACKGROUND

The ways in which traumatic stress symptoms unfold under situations of ongoing threat and trauma exposure are poorly understood. The current study aims to identify traumatic stress symptom trajectories during conflict, as well as potential risk factors.

METHODS

Experience sampling methods were used to study traumatic stress symptoms during the 2014 Israel-Gaza conflict in 100 Israeli civilians exposed to rocket fire. Summary reports of traumatic symptoms were made twice-daily for 30 days via mobile phone.

RESULTS

Latent class growth analysis revealed four distinct classes (low, reducing, moderate, and high) characterised by their trajectory of traumatic stress symptoms during the conflict. Female gender, not being in a relationship, and higher prior trauma exposure were identified as potential risk factors.

LIMITATIONS

Data were not collected in the early phase of the conflict, the sample was relatively small, and only traumatic stress symptoms were investigated as outcomes.

CONCLUSIONS

This study identified heterogeneous traumatic stress symptom trajectories among civilians during a conflict, with different subgroups showing distinct response patterns over time, associated with various risk factors. Investigating responses to ongoing trauma, and identifying predictors of different stress symptom trajectories has clinical implications for the targeted delivery of interventions. Further exploration of heterogeneous trajectories could potentially elucidate mechanisms that drive resilience and recovery, including in situations of ongoing exposure such as during conflict.

Family Social Support Modifies the Relationships Between Childhood Maltreatment Severity, Economic Adversity and Postpartum Depressive Symptoms

OBJECTIVES

This study examines the main and moderating effects of childhood abuse or neglect severity, income, and family social support on the presence of postpartum depressive symptoms (PDS).

METHODS

Participants included 183 postpartum mothers who endorsed a history of childhood maltreatment (CM) and enrolled in a longitudinal study of mother and child outcomes. Participants completed questionnaires to assess CM severity, associated societal and maternal characteristics, and depressive symptom severity.

RESULTS

The results confirm previously identified links between CM severity and PDS. Further, hierarchical linear regression analyses indicate the interaction of household income and interpersonal support from the family attenuates the relationship between CM severity and PDS. The final model accounted for 29% of the variance of PDS scores, a large effect size.

CONCLUSIONS

This study is the first to demonstrate interrelationships between income and social support on resilience to postpartum psychopathology in childhood trauma-surviving women. Social support appeared to protect against PDS for all mothers in this study while income only conferred a protective effect when accompanied by family support. For clinicians, this implies the need to focus on improving family and other relationships, especially for at-risk mothers.

Effect of Previous Posttraumatic Stress in the Perinatal Period

OBJECTIVE

To review the extant literature on the effect of traumatic experiences that pre-date conception, pregnancy, and the postpartum period (perinatal period) and present a thematic overview of current issues in this relatively new area of inquiry.

DATA SOURCES

Electronic databases Cochrane, CINAHL, PsychINFO, and PubMed were searched. Manual searches of reference lists supplemented the electronic search.

STUDY SELECTION

Peer-reviewed articles written in English on the role of posttraumatic stress disorder during the perinatal period were included.

DATA EXTRACTION

Key findings relevant to perinatal posttraumatic stress that were reported in primary sources and meta-analyses were organized according to themes, including The Role of Childbirth, Comorbidity With Depression and Anxiety, Risk Factors for Perinatal PTSD, High-Risk Health Behaviors, and Association With Adverse Health Outcomes.

DATA SYNTHESIS

Across studies, antenatal posttraumatic stress disorder (PTSD) rates were estimated between 2.3% and 24%, and observed prevalence rates during the postnatal period ranged from 1% to 20%; however, many researchers failed to assess PTSD that existed before or during pregnancy, and when preexisting PTSD is a controlled variable, postpartum rates drop to 2% to 4.7%. In addition to prenatal depression and anxiety and pre-pregnancy history of psychiatric disorders, history of sexual trauma, childhood sexual abuse, intimate partner violence, and psychosocial attributes are risk factors for development or exacerbation of perinatal PTSD.

CONCLUSION

Women's health care providers should evaluate for PTSD in routine mental health assessments during and after pregnancy, especially with a reported history of trauma or the presence of a mood or anxiety disorder. Such screening will allow women to receive needed treatment and referrals and mitigate the potentially negative sequelae of PTSD. Future investigators must recognize the importance of subsyndromal posttraumatic stress symptoms and individual differences in responses to trauma.

Neuroactive steroids and PTSD treatment

This review highlights early efforts to translate pre-clinical and clinical findings regarding the role of neuroactive steroids in stress adaptation and PTSD into new therapeutics for PTSD. Numerous studies have demonstrated PTSD-related alterations in resting levels or the reactivity of neuroactive steroids and their targets. These studies also have demonstrated substantial variability in the dysfunction of specific neuroactive steroid systems among PTSD subpopulations. These variabilities have been related to the developmental timing of trauma, severity and type of trauma, genetic background, sex, reproductive state, lifestyle influences such as substance use and exercise, and the presence of comorbid conditions such as depression and chronic pain. Nevertheless, large naturalistic studies and a small placebo-controlled interventional study have revealed generally positive effects of glucocorticoid administration in preventing PTSD after trauma, possibly mediated by glucocorticoid receptor-mediated effects on other targets that impact PTSD risk, including other neuroactive steroid systems. In addition, clinical and preclinical studies show that administration of glucocorticoids, 17β-estradiol, and GABAergic neuroactive steroids or agents that enhance their synthesis can facilitate extinction and extinction retention, depending on dose and timing of dose in relation to these complex PTSD-relevant recovery processes. This suggests that clinical trials designed to test neuroactive steroid therapeutics in PTSD may benefit from such considerations; typical continuous dosing regimens may not be optimal. In addition, validated and clinically accessible methods for identifying specific neuroactive steroid system abnormalities at the individual level are needed to optimize both clinical trial design and precision medicine based treatment targeting.

Understanding Bidirectional Mother-Infant Affective Displays across Contexts: Effects of Maternal Maltreatment History and Postpartum Depression and PTSD Symptoms

BACKGROUND

This study examined the bidirectional nature of mother-infant positive and negative emotional displays during social interactions across multiple tasks among postpartum women accounting for childhood maltreatment severity. Additionally, effects of maternal postpartum psychopathology on maternal affect and effects of task and emotional valence on dyadic emotional displays were evaluated.

SAMPLING AND METHODS

A total of 192 mother-infant dyads (51% male infants) were videotaped during free play and the Still-Face paradigm at 6 months postpartum. Mothers reported on trauma history and postpartum depression and posttraumatic stress disorder (PTSD) symptoms. Reliable, masked coders scored maternal and infant positive and negative affect from the videotaped interactions.

RESULTS

Three path models evaluated whether dyadic affective displays were primarily mother driven, infant driven, or bidirectional in nature, adjusting for mothers' maltreatment severity and postpartum psychopathology. The bidirectional model had the best fit. Child maltreatment severity predicted depression and PTSD symptoms, and maternal symptoms predicted affective displays (both positive and negative), but the pattern differed for depressive symptoms compared to PTSD symptoms. Emotional valence and task altered the nature of bidirectional affective displays.

CONCLUSIONS

The results add to our understanding of dyadic affective exchanges in the context of maternal risk (childhood maltreatment history, postpartum symptoms of depression and PTSD). Findings highlight postpartum depression symptoms as one mechanism of risk transmission from maternal maltreatment history to impacted parent-child interactions. Limitations include reliance on self-reported psychological symptoms and that the sample size prohibited testing of moderation analyses. Developmental and clinical implications are discussed.

Comorbid trajectories of postpartum depression and PTSD among mothers with childhood trauma history: Course, predictors, processes and child adjustment

BACKGROUND

Both postpartum depression and posttraumatic stress disorder (PTSD) have been identified as unique risk factors for poor maternal psychopathology. Little is known, however, regarding the longitudinal processes of co-occurring depression and PTSD among mothers with childhood adversity. The present study addressed this research gap by examining co-occurring postpartum depression and PTSD trajectories among mothers with childhood trauma history.

METHODS

177 mothers with childhood trauma history reported depression and PTSD symptoms at 4, 6, 12, 15 and 18 months postpartum, as well as individual (shame, posttraumatic cognitions, dissociation) and contextual (social support, childhood and postpartum trauma experiences) factors.

RESULTS

Growth mixture modeling (GMM) identified three comorbid change patterns: The Resilient group (64%) showed the lowest levels of depression and PTSD that remained stable over time; the Vulnerable group (23%) displayed moderately high levels of comorbid depression and PTSD; and the Chronic High-Risk group (14%) showed the highest level of comorbid depression and PTSD. Further, a path model revealed that postpartum dissociation, negative posttraumatic cognitions, shame, as well as social support, and childhood and postpartum trauma experiences differentiated membership in the Chronic High-Risk and Vulnerable. Finally, we found that children of mothers in the Vulnerable group were reported as having more externalizing and total problem behaviors.

LIMITATIONS

Generalizability is limited, given this is a sample of mothers with childhood trauma history and demographic risk.

CONCLUSIONS

The results highlight the strong comorbidity of postpartum depression and PTSD among mothers with childhood trauma history, and also emphasize its aversive impact on the offspring.