Preventing postpartum depression: a meta-analytic review

Influential Factors of Depression in Patients with Moderate and Severe Acne

Background: Acne is one of the most common skin diseases and is frequently associated with depression, social isolation, and suicidal ideation. Some studies have investigated the link of either acne or depression and serum levels of vitamin B12 and folic acid (FA), but none appear to have examined the effect of these vitamins on acne patients with or without depression. Objective: This case-control study sought to assess whether serum levels of vitamin B12 and FA could be considered possible predictors for depression and acne severity in patients with moderate and severe acne. Methods: Forty patients with acne and 40 age- and sex-matched healthy volunteers were enrolled. Acne severity and depression were assessed according to the Global Acne Grading System (GAGS) and the Arabic version of the Beck Depression Inventory II (BDI-II), respectively. Five milliliters of blood was obtained by clean venipuncture to determine B12 and FA levels by way of double-antibody sandwich enzyme-linked immunosorbent assay. Results: According to GAGS score, moderate acne was the most prominent form of the condition (55%), followed by severe (25%) and very severe (20%). Seventy percent of patients with acne had depression according to BDI-II score versus zero percent in the control group (p<0.001). Patients with moderate and severe acne in this study had significantly lower serum levels of vitamin B12 and FA when compared to controls (p=0.012 and p<0.001) and their levels showed a significant negative correlation with acne severity according to GAGS score. Conclusion: Screening for vitamin B12 and FA deficiency can be particularly relevant in patients with acne to assess depression risk. Folate supplementation should be considered for patients with acne and comorbid depression.

Effectiveness of a group intervention led by lay health workers in reducing the incidence of postpartum depression in South India

BACKGROUND

Postnatal depression is a highly prevalent disorder with serious implications on maternal and child outcomes. There are few studies examining feasible interventions in low-middle-income community settings.

AIMS

To assess the effectiveness of a low intensity group intervention led by lay workers during the antenatal period in reducing postnatal depression at 6-2 weeks postpartum.

METHODS

A parallel group design with both positive and negative controls was employed. 1 community site was allocated to each of the 3 arms. The active intervention consisted of problem based sessions with cognitive behavioural components. The primary outcome was the presence of depression on CIS-R and secondary outcome measures where Global Assessment of Functioning (GAF) scores, EPNDS scores and participant perceptions.

RESULTS

69, 75 and 70 women received active, positive control and negative control interventions respectively. Post partum depression diagnosed with the CIS-R was present in 14.06% (C.I.- 5.55%-22.57%) and 22.62% (C.I.15.62%-29.63%) in the active arm and two control (combined) arms respectively. There was a 1/3 lower proportion of postpartum depression and impaired functioning in the intervention group, though statistical significance was not reached (p = 0.30). There were high levels of satisfaction reported for the active intervention.

CONCLUSION

There were trends for the possible effectiveness for this low intensity intervention and conclusions regarding its effectiveness can't be made as the sample size was small. There is a need to explore and develop locally relevant, innovative and feasible strategies for prevention of postnatal depression in resource constrained enviroments.

Save the children by treating their mothers (PriVileG-M-study) - study protocol: a sequentially randomized controlled trial of individualized psychotherapy and telemedicine to reduce mental stress in pregnant women and young mothers and to improve Child's health

BACKGROUND

As early as pregnancy, maternal mental stress impinges on the child's development and health. Thus, this may cause enhanced risk for premature birth, lowered fetal growth, and lower fetal birth weight as well as enhanced levels of the stress hormone cortisol and lowered levels of the bonding hormone oxytocin. Maternal stress further reduces maternal sensitivity for the child's needs which impairs the mother-child-interaction and bonding. Therefore, prevention and intervention studies on mental stress are necessary, beginning prenatally and applying rigorous research methodology, such as randomized controlled trials, to ensure high validity.

METHODS

A randomized controlled trial is used to assess the impact of psychotherapy and telemedicine on maternal mental stress and the child's mental and physical health. Mentally stressed pregnant women are randomized to an intervention (IG) and a not intervened control group. The IG receives an individualized psychotherapy starting prenatal and lasting for 10 months. Afterwards, a second randomization is used to investigate whether the use of telemedicine can stabilize the therapeutic effects. Using ecological momentary assessments and video recordings, the transfer into daily life, maternal sensitivity and mother-child-bonding are assessed. Psycho-biologically, the synchronicity of cortisol and oxytocin levels between mother and child are assessed as well as the peptidome of the colostrum and breast milk, which are assumed to be essential for the adaptation to the extra-uterine environment. All assessments are compared to an additional control group of healthy women. Finally, the results of the study will lead to the development of a qualification measure for health professionals to detect mental stress, to treat it with low-level interventions and to refer those women with high stress levels to mental health professionals.

DISCUSSION

The study aims to prevent the transgenerational transfer of psychiatric and somatic disorders from the mother to her child. The effects of the psychotherapy will be stabilized through telemedicine and long-term impacts on the child's and mothers' mental health are enhanced. The combination of psychotherapy, telemedicine and methodologies of ecological momentary assessment, video recording and bio banking are new in content-related and methodological manner.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00017065. Registered 02 May 2019. World Health Organization, Universal Trial Number: U1111-1230-9826. Registered 01 April 2019.

Preventing perinatal depression in Spain: a pilot evaluation of Mamás y Bebés

Objective: This pilot study evaluated the feasibility, acceptability, and preliminary effectiveness of a cognitive-behavioural intervention to prevent perinatal depressive symptoms in pregnant women at high risk for perinatal depression in Spain. Background: Perinatal depression (PD) can negatively affect maternal and infant outcomes. Mamás y Bebés/The Mothers and Babies Course (MBC) is an evidence-based CBT intervention aimed at teaching women at high risk for depression mood regulation skills to prevent depression in the United States, including Spanish-speaking perinatal women in the United States. However, there is limited research on preventive interventions for PD in Spain. Method: Pregnant women screened for high risk for PD were recruited in their first trimester in an obstetrics clinic at two urban hospitals in Spain. In a non-experimental design, 30 women completed eight weekly group sessions of the MBC. The Patient Health Questionnaire was the main depression outcome at four time points: pre-intervention, post-intervention, and at 3 months and 6 months postpartum. Participants completed an evaluation questionnaire at the end of each session to assess the acceptability of the intervention. Results: The MBC was effective in reducing depressive symptoms from baseline to all three time points: post-intervention, 3 and 6 months postpartum. Attendance was high (76.7% attended all eight sessions). Mothers reported positive feedback from the participating in the MBC. Conclusion: This pilot study suggests that the intervention is feasible, acceptable, and provides promising evidence for reducing depressive symptoms in urban Spanish perinatal women. Larger and rigorous randomised trials are needed to confirm these findings.

Effect of social support and health education on depression scale scores of chronic stroke patients

Post-stroke depression (PSD) constitutes an important complication of stroke, leading to great disability. After stroke, the prevalence rate of depression is about 30%. Depression also affects rehabilitation motivation, delays function recovery, and increases family and social burden. The objective of this study was to explore the effect of social support on depression in chronic stroke patients and the relationship between demographic and disease characteristics. Total samples were randomly divided into an intervention group (n = 31) and a control group (n = 31). Sixteen social support interventions were performed over 8 weeks. Social support programs were implemented 2 times a week. Depressive symptoms were assessed at the second week, 4th week, 8th week, and 4 weeks after the end of the study using the 10-item Center for the Epidemiological Studies of Depression Short Form (CES-D10). There was a significant correlation between depression and the economic status of the patients with chronic stroke, satisfaction in leisure, the presence or absence of caregivers, the duration of stroke, and with or without pain. A significant difference was found between two groups after social support for 8 weeks. Our findings suggest that remission of PSD needs at least 8 weeks of social support.

Prevalence of perinatal depression among HIV-positive women: a systematic review and meta-analysis

BACKGROUND

Increasing attention has been paid to differences in the prevalence of perinatal depression by HIV status, although inconsistent results have been reported. The aim of this systematic review and meta-analysis was to assess the relationship between perinatal depression and HIV infection. A comprehensive meta-analysis of comparative studies comparing the prevalence of antenatal or postnatal depression between HIV-infected women and HIV-negative controls was conducted.

METHODS

Studies were identified through PubMed/Medline, Scopus, Web of Science, Cochrane Library, Embase and PsycINFO, and the reading of complementary references in August 2019. Subgroup analyses were performed for anticipated explanation of heterogeneity using methodological quality and pre-defined study characteristics, including study design, geographical location and depression screening tools for depression. The overall odds ratio (OR) and mean prevalence of each group were calculated.

RESULTS

Twenty-three studies (from 21 publications), thirteen regarding antenatal depression and ten regarding postnatal depression were included, comprising 3165 subjects with HIV infection and 6518 controls. The mean prevalence of antenatal depressive symptoms in thirteen included studies was 36% (95% CI: 27, 45%) in the HIV-positive group and 26% (95% CI: 20, 32%) in the control group. The mean prevalence of postnatal depressive symptoms in ten included studies was 21% (95% CI: 14, 27%) in the HIV-positive group and 16% (95% CI: 10, 22%) in the control group. Women living with HIV have higher odds of antenatal (OR: 1.42; 95% CI: 1.12, 1.80) and postnatal depressive symptoms (OR: 1.58; 95% CI: 1.08, 2.32) compared with controls. Publication bias and moderate heterogeneity existed in the overall meta-analysis, and heterogeneity was partly explained by the subgroup analyses.

CONCLUSIONS

Women with HIV infection exhibit a significantly higher OR of antenatal and postnatal depressive symptoms compared with controls. For the health of both mother and child, clinicians should be aware of the significance of depression screening before and after delivery in this particular population and take effective measures to address depression among these women.

Prophylactic use of ketamine reduces postpartum depression in Chinese women undergoing cesarean section✰

This study aimed to explore the effect of prophylactic ketamine administration on postpartum depression in Chinese woman undergoing cesarean section. This randomized controlled study included 654 Chinese women undergoing cesarean section. At 10 min after child birth, patients in the ketamine group were given 0.5 mg/kg ketamine, whereas patients in the control group received standard postpartum care. At the end of operation, all patients were armed with a patient-controlled intravenous analgesia device. The primary outcome was the prevalence of postpartum depression (PPD), as assessed by the Edinburgh Postnatal Depression Scale (EPDS), and the secondary outcomes included the safety assessment and the Numerical Rating Scale (NRS) of postoperative pain. The prevalence of postpartum blues and postpartum depression were significantly lower in the ketamine group than in the control group. Logistic analysis showed that ketamine administration protected against postpartum depression, and PPD-associated risk factors included stress during pregnancy, antenatal depressive symptom and antenatal suicidal ideation. In addition, the antidepressive effect of prophylactic ketamine was stronger in mothers with a history of moderate stress during pregnancy, antenatal depressive symptom and antenatal suicidal ideation. Our findings suggest that ketamine functions as a prophylactic agent against PPD.

A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial

BACKGROUND

Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions.

OBJECTIVES

This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes.

METHODS

User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum.

RESULTS

A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment.

CONCLUSIONS

Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121015; https://clinicaltrials.gov/ct2/show/NCT02121015 (archived by WebCite at http://www.webcitation.org/765a7qBKy).

Cognitive correlates of women's postpartum depression risk and symptoms: the contribution of dysfunctional beliefs and negative thoughts

Background: Despite the extensive research on interpersonal and clinical risk factors for postpartum depression (PPD), there is a paucity of research on the potential role of cognitive variables (dysfunctional beliefs and negative thoughts) as correlates of PPD symptoms.Aims: This exploratory study aimed to understand the cognitive processes of women at a higher risk (i.e. presenting well-established interpersonal and clinical risk factors) for PPD by: (a) comparing women's dysfunctional motherhood-related beliefs and frequency of automatic thoughts, as a function of their levels of PPD risk and symptoms; (b) examining the cognitive correlates of PPD symptoms, controlling for the presence of well-established risk factors.Method: A cross-sectional internet survey comprising 441 postpartum women was conducted.Results: Women presenting high-risk for PPD showed more dysfunctional motherhood-related attitudes (p < 0.001), more frequent negative thoughts (p < 0.001) and less frequent positive thoughts (p < 0.001) than low-risk women. More dysfunctional beliefs related to maternal responsibility, more frequent negative thoughts related with personal maladjustment and with the metacognitive appraisal of the thoughts' content, and less frequent positive thoughts were found to be significantly associated with PPD symptoms.Conclusion: The inclusion of cognitive variables in risk assessment and preventive efforts for PPD may hold potential to increase its clinical efficacy.

Management of perinatal depression with non-drug interventions

Perinatal depression is a common disorder that has been associated with serious risks to mother and child. Recently, screening for depression in pregnant and postpartum women has increased, as has the development of new psychotherapy and non-drug treatment modalities. Matching patients to treatments can be challenging, and although research into personalized treatment of major depression in the general population has increased, no published guidelines focus on personalized treatment approaches to perinatal depression. In particular, guidelines on non-drug treatments are lacking. This review summarizes the evidence on personalized non-drug treatment of perinatal depression, how to incorporate patients' preferences, novel treatments under investigation, and the potential role of biomarkers in matching patients to treatment. The review provides recommendations for future research in personalized care of perinatal depression.

Interventions to Prevent Perinatal Depression: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Depression during pregnancy and the postpartum period is relatively common and can have adverse effects on both mother and child.

OBJECTIVE

To systematically review benefits and harms of primary care-relevant interventions to prevent perinatal depression, a major or minor depressive episode during pregnancy or up to 1 year after childbirth, to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMED (for publisher-supplied records only), PsycINFO, and the Cochrane Central Register of Controlled Trials; surveillance through December 5, 2018.

STUDY SELECTION

Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies of interventions (eg, behavior-based, antidepressants, dietary supplements) to prevent perinatal depression in general populations of pregnant and postpartum individuals or in those at increased risk of perinatal depression. Large cohort studies were considered for harms of antidepressant use only.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently reviewed abstracts and full-text articles and quality rated included studies. Random-effects meta-analysis was used to estimate the benefits of the interventions.

MAIN OUTCOMES AND MEASURES

Depression status; depression symptoms; maternal, infant, and child health outcomes.

RESULTS

Fifty studies (N = 22 385) that met inclusion criteria were identified. Counseling interventions were the most widely studied interventions. Compared with controls, counseling interventions were associated with a lower likelihood of onset of perinatal depression (pooled risk ratio [RR], 0.61 [95% CI, 0.47-0.78]; 17 RCTs [n = 3094]; I2 = 39.0%). The absolute difference in the risk of perinatal depression ranged from 1.3% greater reduction in the control group to 31.8% greater reduction in the intervention group. Health system interventions showed a benefit in 3 studies (n = 5321) and had a pooled effect size similar to that of the counseling interventions, but the pooled effect was not statistically significant using a method appropriate for pooling a small number of studies (restricted maximum likelihood RR, 0.58 [95% CI, 0.22-1.53]; n = 4738; I2 = 66.3%; absolute risk reduction range, -3.1% to -13.1%). None of the behavior-based interventions reported on harms directly. A smaller percentage of participants prescribed sertraline had a depression recurrence compared with those prescribed placebo (7% vs 50%, P = .04) at 20 weeks postpartum in 1 very small RCT (n = 22 analyzed) but with an increased risk of adverse effects to the mother.

CONCLUSIONS AND RELEVANCE

Counseling interventions can be effective in preventing perinatal depression, although most evidence was limited to women at increased risk for perinatal depression. A variety of other intervention approaches provided some evidence of effectiveness but lacked a robust evidence base and need further research.

Impact of prenatal exercise on both prenatal and postnatal anxiety and depressive symptoms: a systematic review and meta-analysis

Objective

To examine the influence of prenatal exercise on depression and anxiety during pregnancy and the postpartum period.

Design

Systematic review with random effects meta-analysis and meta-regression.

Data sources

Online databases were searched up to 6 January 2017.

Study eligibility criteria

Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcome (prenatal or postnatal depression or anxiety).

Results

A total of 52 studies (n=131 406) were included. ‘Moderate’ quality evidence from randomised controlled trials (RCTs) revealed that exercise-only interventions, but not exercise+cointerventions, reduced the severity of prenatal depressive symptoms (13 RCTs, n=1076; standardised mean difference: −0.38, 95% CI −0.51 to –0.25, I2=10%) and the odds of prenatal depression by 67% (5 RCTs, n=683; OR: 0.33, 95% CI 0.21 to 0.53, I2=0%) compared with no exercise. Prenatal exercise did not alter the odds of postpartum depression or the severity of depressive symptoms, nor anxiety or anxiety symptoms during or following pregnancy. To achieve at least a moderate effect size in the reduction of the severity of prenatal depressive symptoms, pregnant women needed to accumulate at least 644 MET-min/week of exercise (eg, 150 min of moderate intensity exercise, such as brisk walking, water aerobics, stationary cycling, resistance training).

Summary/Conclusions

Prenatal exercise reduced the odds and severity of prenatal depression.

Risk factors of new onset anxiety and anxiety exacerbation in the perinatal period: A systematic review and meta-analysis

BACKGROUND

Even though more than 20% of women meet diagnostic criteria for an anxiety disorder during the perinatal period, very little is known about the predictors of these problems. As a result, we systematically reviewed the literature on risk factors for new onset anxiety and maternal anxiety exacerbation in the perinatal period.

METHODS

PubMed, MEDLINE, PsycINFO, CINAHL, Ovid, ProQuest Portal, and Web of Science were searched for studies assessing risk factors for the development of new onset anxiety or anxiety worsening in women during pregnancy and the postpartum period.

RESULTS

11,759 citations were identified, with 11 studies meeting eligibility criteria. New onset anxiety was assessed in 7 studies, anxiety worsening in 3, and 1 assessed both. Lower educational attainment, living with extended family members, multiparity, a family history of psychiatric disorders, hyperemesis gravidarum, comorbid sleep disorders, and prenatal oxytocin exposure were risk factors for new onset perinatal anxiety, while presence of comorbid psychiatric disorders and prenatal oxytocin were risk factors for anxiety worsening.

LIMITATIONS

Studies not explicitly stating whether participants had pre-existing anxiety disorders were excluded. As a result, meta-analysis was not possible for several risk factors.

CONCLUSIONS

Risk factors for new onset anxiety and anxiety worsening during the perinatal period include psychological, social, and biological exposures. Given the lack of studies differentiating women with and without pre-existing anxiety disorders, additional research is required in order to determine whether these factors differ from the non-puerperal population, as well as from each other.

Gene expression profile in peripheral blood mononuclear cells of postpartum depression patients

Postpartum depression (PPD) is a common mental health problem that causes maternal suffering and various negative consequences for offspring. The pathogenesis of PPD and the causes of consequences for offspring remain largely unknown. Here, we applied RNA sequencing to sequence the whole transcriptomes of peripheral blood mononuclear cells (PBMCs) from PPD patients (Edinburgh Postnatal Depression Scale [EPDS] score ≥13) and control subjects (EPDS = 0). We found that PPD was positively correlated with multiple genes involved in energy metabolism, neurodegenerative diseases and immune response, while negatively correlated with multiple genes in mismatch repair and cancer-related pathways. Remarkably, genes associated with appetite regulation and nutrient response were differentially expressed between PPD and control subjects. Then, we employed a postnatal growth retardation model by repeated immobilization stress (IS) stimulation to maternal mice. The expression of appetite regulation and nutrient response-related genes in the PBMCs of IS mice and in the hypothalamus of their offspring were also affected. In conclusion, this study provides a comprehensive characterization of the PBMCs transcriptome in PPD and suggests that maternal stress may affect appetite regulation and nutrient response in the hypothalamus of offspring mice.

Physical exercise programme during pregnancy decreases perinatal depression risk: a randomised controlled trial

Introduction

The incidence of depression is high during the perinatal period. This mood disorder can have a significant impact on the mother, the child and the family.

Objective

To examine the effect of an exercise programme during pregnancy on the risk of perinatal depression.

Methods

Healthy women who were <16 weeks pregnant were randomly assigned to two different groups. Women in the intervention group participated in a 60 min exercise programme throughout pregnancy, 3 days per week, which was conducted from October 2014 to December 2016. The Center for Epidemiological Studies-Depression Scale was used to measure the risk of depression at the beginning of the study (12–16 weeks), at gestational week 38 and at 6 weeks postpartum.

Results

One hundred and twenty-four pregnant women were allocated to either the intervention (IG=70) or the control (CG=54) group. No differences were found in the percentage of depressed women at baseline (20% vs 18.5%) (χ2=0.043; p=0.836). A smaller percentage of depressed women were identified in the IG compared with the CG at 38 gestational weeks (18.6% vs 35.6%) (χ2=4.190; p=0.041) and at 6 weeks postpartum (14.5% vs 29.8%) (χ2=3.985; p=0.046) using the per-protocol analysis. No significant differences were found using the intention-to-treat analyses, except in the multiple imputation analysis at week 38 (18.6% vs 34.4%) (χ2=4.085; p=0.049).

Conclusion

An exercise programme performed during pregnancy may reduce the prevalence of depression in late pregnancy and postpartum.

Trial registration number

NCT02420288; Results.

A systematic review and meta-analysis of interpersonal psychotherapy for perinatal women

BACKGROUND

Interpersonal psychotherapy (IPT) has demonstrated efficacy for the prevention and treatment of perinatal depression. Previous systematic reviews have not evaluated the effects of IPT on other outcomes, most notably symptoms of anxiety and interpersonal functioning, or assessed moderators of treatment efficacy specific to IPT.

METHOD

A systematic review identified 28 studies assessing the efficacy of IPT during pregnancy or the first year postpartum. Random effects meta-analyses assessed the average change in outcomes (depression, anxiety, relationship quality, social adjustment, and social support) from pre- to post-treatment, the difference in the change in outcomes between treatment and comparison conditions, and the difference in prevalence of depressive episodes between treatment and comparison conditions. Study, intervention, and sample characteristics were evaluated as potential moderators of effect sizes.

RESULTS

In prevention studies, IPT was effective for reducing depressive symptoms and the prevalence of depressive episodes. In treatment studies, IPT reduced symptoms of depression and anxiety and improved relationship quality, social adjustment and social support. Few significant moderators were identified, and results of moderation analyses were inconsistent across outcomes.

LIMITATIONS

There are insufficient studies to evaluate the effects of preventive IPT on anxiety and interpersonal outcomes. Analyses of potential moderators were limited by the number of studies available for subgroup comparisons.

CONCLUSIONS

IPT is an effective preventive intervention for perinatal depression. IPT is clearly effective for treating depressive symptoms and promising as a treatment for anxiety and improving interpersonal functioning. Further research is necessary to assess whether adaptations to IPT enhance its efficacy.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Professional issues in maternal mental health scale (PIMMHS): The development and initial validation of a brief and valid measure

INTRODUCTION

The life-threatening consequences of perinatal mental health problems (PMHP) are well documented. Midwives are ideally placed to effectively identify women at risk and facilitate early intervention. However, a multitude of factors contribute to failure in recognition and treatment. It would be of value for service providers to be able to identify key professional issues in their own context. The present study sought to develop and evaluate a 'professional issues in maternal mental health' scale (PIMMHS), explore its psychometric properties and potential application.

METHODS

A cross-sectional design and instrument evaluation approach was taken to investigate the psychometric properties of the PIMMHS. A total of 266 student midwives from 10 UK institutions completed the PIMMHS via Survey Monkey.

RESULTS

PIMMHS comprises two sub-scales of emotion/communication (PIMMHSEmotion sub-scale) and training (PIMMHS-Training sub-scale). Both PIMMHS subscales demonstrate adequate divergent and convergent validity. Sub-optimal internal consistency was observed for the training sub-scale, however, the PIMMHS-Training had a more impressive effect size in terms of known-groups discriminant validity compared to PIMMHS-Emotion.

CONCLUSIONS

The PIMMHS appears to be a sound psychometric instrument for assessing professional issues that influence the practice of student midwives in PMH. The PIMMHS could support education providers to identify areas for curriculum development, as well as maternity services in proactive assessment of service provision, to identify training and service development opportunities.

Association between Duration of Folic Acid Supplementation during Pregnancy and Risk of Postpartum Depression

Postpartum depression (PPD), as a common complication of childbearing, could have adverse consequences on mothers, children, and families. This cohort study aimed to assess the association between duration of folic acid (FA) supplementation during pregnancy and the onset of PPD in Chinese women. A total of 1592 participants were recruited, and data collected between July 2015 and March 2017 in Tianjin, China. Participants’ baseline data were collected regarding socio-demographic and lifestyle characteristics, obstetric history, and FA supplementation during pregnancy. The Chinese version of the self-rating depression scale was used to assess depressive symptoms at 6–12 weeks postpartum, and the prevalence of PPD in participants was 29.4%. Pregnant women who took FA supplements for >6 months had a lower prevalence of PPD, compared to those who took FA for ≤6 months. After using the 1:1 ratio propensity score matching, 601 FA-users ≤ 6 months and 601 FA-users > 6 months were included in the further analyses; this also yielded similar results (P < 0.05). Logistic regression analysis showed that FA intake for >6 months was an independent determinant of PPD (odds ratio = 0.76; 95% confidence interval: 0.59–0.98; P < 0.05). Thus, prolonged FA supplementation during pregnancy was associated with a decreased risk of PPD in Chinese women.

Hair cortisol levels, psychological stress and psychopathological symptoms as predictors of postpartum depression

Postpartum depression affects a huge number of women and has detrimental consequences. Knowing the factors associated with postpartum depression during pregnancy can help its prevention. Although there is evidence surrounding behavioral or psychological predictors of postpartum depression, there is a lack of evidence of biological forecasters. The aim of this study was to analyze the sociodemographic, obstetric, and psychological variables along with hair cortisol levels during the first, second, and third trimesters of pregnancy that could predict postpartum depression symptoms. A sample of 44 pregnant women was assessed during 3 trimesters of pregnancy and the postpartum period using psychological questionnaires and hair cortisol levels. Participants were divided into 2 groups: a group with postpartum depression symptoms and a group with no postpartum depression symptoms. Results showed significant positive differences between groups in the first trimester regarding the Somatization subscale of the SCL-90-R (p < .05). In the second trimester, significant differences were found in the Somatization, Depression, Anxiety, and GSI subscales (p < .05). In the third trimester significant differences between both groups were found regarding pregnancy-specific stress. We found significant positive differences between groups regarding hair cortisol levels in the first and the third trimester. Hair cortisol levels could predict 21.7% of the variance of postpartum depression symptoms. In conclusion, our study provided evidence that psychopathological symptoms, pregnancy-specific stress, and hair cortisol levels can predict postpartum depression symptoms at different time-points during pregnancy. These findings can be applied in future studies and improve maternal care in clinical settings.

Retinoids, anxiety and peripartum depressive symptoms among Chinese women: a prospective cohort study

BACKGROUND

The current study aimed to investigate whether serum RBP levels can be a key predictor of peripartum depression (PPD).

METHODS

This was a prospective cohort study, conducted at a general teaching hospital in South China. Research participants were evaluated at three time points: the third trimester of pregnancy (T1), after delivery at week one (T2), and after delivery week six (T3) using a set of self-reported questionnaires and blood sample assays.

RESULTS

A total of 156 subjects were included for data analysis. The prevalence of anxiety symptoms ranged from 32.69% to 36.53%. The prevalence of PPD was also high and ranged from 27.56% to 35.89%. In the third trimester, significant predictors of depressive symptoms include serum retinol-binding protein (RBP) concentrations and estradiol levels (P = 0.008 and 0.033, respectively). At one week after delivery, serum concentrations of RBP at T2 were still significant predictors of depressive symptoms (P = 0.020, and serum estradiol concentrations at T1 were a significant predictor (P = 0.010). The most stable predictor of depressive symptoms at T3 was anxiety symptoms, especially at T3 time point (P < 0.001). Serum RBP concentrations at T1 and T2 were still significant predictors of depressive symptoms at T3.

CONCLUSION

A high prevalence of anxiety and depressive symptoms tended to persist in Chinese women during the peripartum period. This study, which found the potential contribution of RBP to the occurrence of PPD, requires that large sample studies be conducted in future with a longer-term follow-up period, in order to confirm its results.

Effects of Exercise on Mild-to-Moderate Depressive Symptoms in the Postpartum Period: A Meta-analysis

OBJECTIVE

To examine the influence of exercise on depressive symptoms and the prevalence of depression in the postpartum period.

DATA SOURCES

A structured search of MEDLINE, EMBASE, CINAHL, Sport Discus, Ovid's All EBM Reviews, and ClinicalTrials.gov databases was performed with dates from the beginning of the databases until June 16, 2016. The search combined keywords and MeSH-like terms including, but not limited to, "exercise," "postpartum," "depression," and "randomized controlled trial."

METHODS OF STUDY SELECTION

Randomized controlled trials comparing postpartum exercise (structured, planned, repetitive physical activity) with the standard care for which outcomes assessing depressive symptoms or depressive episodes (as defined by trial authors) were assessed. Trials were identified as prevention trials (women from the general postpartum population) or treatment trials (women were classified as having depression by the trial authors). Effect sizes with 95% confidence intervals (CIs) were calculated using Hedges' g method and standardized mean differences in postintervention depression outcomes were pooled using a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

Across all 16 trials (1,327 women), the pooled standardized mean difference was -0.34 (95% CI -0.50 to -0.19, I=37%), suggesting a small effect of exercise among all postpartum women on depressive symptoms. Among the 10 treatment trials, a moderate effect size of exercise on depressive symptoms was found (standardized mean difference-0.48, 95% CI -0.73 to -0.22, I=42%). In six prevention trials, a small effect (standardized mean difference-0.22, 95% CI -0.36 to -0.08, I=2%) was found. In women with depression preintervention, exercise increased the odds of resolving depression postintervention by 54% (odds ratio 0.46, Mantel-Haenszel method, 95% CI 0.25-0.84, I=0%). The trials included in this meta-analysis were small and some had methodologic limitations.

CONCLUSION

Light-to-moderate intensity aerobic exercise improves mild-to-moderate depressive symptoms and increases the likelihood that mild-to-moderate depression will resolve.

Depressive symptoms and gestational length among pregnant adolescents: Cluster randomized control trial of CenteringPregnancy® plus group prenatal care

OBJECTIVES

Depressive symptoms are associated with preterm birth among adults. Pregnant adolescents have high rates of depressive symptoms and low rates of treatment; however, few interventions have targeted this vulnerable group. Objectives are to: (a) examine impact of CenteringPregnancy® Plus group prenatal care on perinatal depressive symptoms compared to individual prenatal care; and (b) determine effects of depressive symptoms on gestational age and preterm birth among pregnant adolescents.

METHOD

This cluster-randomized controlled trial was conducted in 14 community health centers and hospitals in New York City. Clinical sites were randomized to receive standard individual prenatal care (n = 7) or CenteringPregnancy® Plus group prenatal care (n = 7). Pregnant adolescents (ages 14-21, N = 1,135) completed the Center for Epidemiologic Studies Depression Scale during pregnancy (second and third trimesters) and postpartum (6 and 12 months). Gestational age was obtained from medical records, based on ultrasound dating. Intention to treat analyses were used to examine objectives.

RESULTS

Adolescents at clinical sites randomized to CenteringPregnancy® Plus experienced greater reductions in perinatal depressive symptoms compared to those at clinical sites randomized to individual care (p = .003). Increased depressive symptoms from second to third pregnancy trimester were associated with shorter gestational age at delivery and preterm birth (<37 weeks gestation). Third trimester depressive symptoms were also associated with shorter gestational age and preterm birth. All p < .05.

CONCLUSIONS

Pregnant adolescents should be screened for depressive symptoms prior to third trimester. Group prenatal care may be an effective nonpharmacological option for reducing depressive symptoms among perinatal adolescents. (PsycINFO Database Record

A randomized controlled trial of vitamin D supplementation on perinatal depression: in Iranian pregnant mothers

Background

Mood disorders in pregnancy and post-partum period are common and considered as a public health issue. Researchers have studied the relationship between low serum vitamin D concentration and perinatal depression, although no clinical trial has been conducted on vitamin D’s effects on depression related to childbirth. This study evaluated the effect of vitamin D₃ supplementation on perinatal depression scores.

Methods

This randomized clinical trial was done in pregnant women who were under prenatal care in a teaching hospital in Shiraz, Iran. The inclusion criteria were: being 18 years or older, no history of mental illness and internal diseases, a singleton live fetus, without any pregnancy complications, gestational age of 26–28 weeks upon enrollment, and depression score of 0 to 13. The Edinburgh Postnatal Depression scale was used to evaluate depression scores. A total of 169 participants were assigned to the two groups of placebo and vitamin D through block randomization design. Vitamin D group received 2000 IU vitamin D₃ daily from 26 to 28 weeks of gestation until childbirth. Maternal serum 25-hydroxyvitamin D concentrations were measured at baseline and childbirth. Besides, depression scores were evaluated four times: at 26–28 and 38–40 weeks of gestation, and finally at 4 and 8 weeks after birth.

Results

The two groups were similar in relation to baseline 25-hydroxyvitamin D concentrations. However, at childbirth, the vitamin D group had significantly higher 25-hydroxyvitamin D concentration in comparison to the control group (p < 0.001). At baseline, no correlation was observed between 25-hydroxyvitamin D concentration and depression score (r = 0.13, p = 0.09). There was no significant difference between the two study groups in relation to the baseline depression score. While, the vitamin D group had greater reduction in depression scores than the control group at 38–40 weeks of gestation (p = 0.01) also, at 4 and 8 weeks after birth (p < 0.001).

Conclusions

The present trial showed that consuming 2000 IU vitamin D₃ daily during late pregnancy was effective in decreasing perinatal depression levels. We suggest further clinical trial in pregnant mothers who are at risk for postnatal depression.

Trial registration

Iranian Registry of Clinical Trials IRCT2015020310327N11. Date of registration: March 9th 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1024-7) contains supplementary material, which is available to authorized users.

Preventing Perinatal Depression in High Risk Women: Moving the Mothers and Babies Course from Clinical Trials to Community Implementation

A growing research literature highlights the public health need for preventive interventions to reduce symptoms and incidence of perinatal depression among vulnerable populations. The Mothers and Babies (MB) course is a cognitive-behavioral intervention designed to teach mood regulation skills to English- and Spanish-speaking low-income women at high risk for perinatal depression. We describe the development of the MB course and evaluate the extent to which research findings support efficacy, effectiveness, and dissemination based on the Society for Prevention Research Standards Committee's standards of evidence. Our review of research and implementation activities suggests that the MB intervention demonstrates promising evidence for efficacy in reducing depressive symptoms; empirical support for prevention of major depressive episodes is still preliminary. Work is in progress to evaluate program effectiveness and prepare for broad dissemination and implementation. The MB course shows promise as an intervention for low-income women at risk for perinatal mood issues. Spanish and English intervention materials have been developed that can be delivered in different settings (hospitals, home visiting), in different dosages (6, 8, or 12 sessions), and via different modalities (group, individual). Evaluating the MB course against current standards is intended to inform other prevention intervention development research.

The neurobiological impact of postpartum maternal depression: prevention and intervention approaches

The lasting negative impact of postpartum depression (PPD) on offspring is well established. PPD seems to have an impact on neurobiological pathways linked to socioemotional regulation, cognitive and executive function, and physiologic stress response systems. This review focus on examining the current state of research defining the effect of universal, selected, and indicated interventions for PPD on infant neurodevelopment. Given the established lasting, and potentially intergenerational, negative implications of maternal depression, enhanced efforts targeting increased identification and early intervention approaches for PPD that have an impact on health outcomes in both infants and mothers represent a critical public health concern.

Lifetime costs of perinatal anxiety and depression

BACKGROUND

Anxiety and depression are common among women during pregnancy and the year after birth. The consequences, both for the women themselves and for their children, can be considerable and last for many years. This study focuses on the economic consequences, aiming to estimate the total costs and health-related quality of life losses over the lifetime of mothers and their children.

METHOD

A pathway or decision modelling approach was employed, based on data from previous studies. Systematic and pragmatic literature reviews were conducted to identify evidence of impacts of perinatal anxiety and depression on mothers and their children.

RESULTS

The present value of total lifetime costs of perinatal depression (anxiety) was £75,728 (£34,811) per woman with condition. If prevalence estimates were applied the respective cost of perinatal anxiety and depression combined was about £8500 per woman giving birth; for the United Kingdom, the aggregated costs were £6.6 billion. The majority of the costs related to adverse impacts on children and almost a fifth were borne by the public sector.

LIMITATIONS

The method was exploratory in nature, based on a diverse range of literature and encountered important data gaps.

CONCLUSIONS

Findings suggest the need to allocate more resources to support women with perinatal mental illness. More research is required to understand the type of interventions that can reduce long-term negative effects for both mothers and offspring.

Depression During Pregnancy and Postpartum

Depression is a common complication of pregnancy and the postpartum period. There are multiple risk factors for peripartum mood disorders, most important of which is a prior history of depression. Both depression and antidepressant medications confer risk upon the infant. Maternal depression has been associated with preterm birth, low birth weight, fetal growth restriction, and postnatal cognitive and emotional complications. Antidepressant exposure has been associated with preterm birth, reductions in birth weight, persistent pulmonary hypertension, and postnatal adaptation syndrome (PNAS) as well as a possible connection with autism spectrum disorder. Paroxetine has been associated with cardiac malformations. Most antidepressant medications are excreted in low levels in breast milk and are generally compatible with breastfeeding. The use of antidepressants during pregnancy and postpartum must be weighed against the risk of untreated depression in the mother.

Affective changes during the postpartum period: Influences of genetic and experiential factors

This article is part of a Special Issue "Parental Care". The postpartum period involves some truly transformational changes in females' socioemotional behaviors. For most female laboratory rodents and women, these changes include an improvement in their affective state, which has positive consequences for their ability to sensitively care for their offspring. There is heterogeneity among females in the likelihood of this positive affective change, though, and some women experience elevated anxiety or depression (or in rodents anxiety- or depression-related behaviors) after giving birth. We aim to contribute to the understanding of this heterogeneity in maternal affectivity by reviewing selected components of the scientific literatures on laboratory rodents and humans examining how mothers' physical contact with her infants, genetics, history of anxiety and depression and early-life and recent-life experiences contribute to individual differences in postpartum affective states. These studies together indicate that multiple biological and environmental factors beyond female maternal state shape affective responses during the postpartum period, and probably do so in an interactive manner. Furthermore, the similar capacity of some of these factors to modulate anxiety and depression in human and rodent mothers suggests cross-species conservation of mechanisms regulating postpartum affectivity.

How to support patients with severe mental illness in their parenting role with children aged over 1 year? A systematic review of interventions

PURPOSE

There are well-established risks for parents with severe mental illness (i.e. psychotic and bipolar disorders), both for their children and themselves. Interventions to help parents fulfil their role should therefore be a public health objective, but their implementation needs to be underpinned by research evidence. This systematic review determines what is known about the nature and effectiveness of interventions for parents with severe mental illness.

METHODS

We conducted a narrative synthesis of controlled and uncontrolled studies reporting interventions for this patient group after the post-natal period (i.e. after the child has turned 1 year old).

RESULTS

Eighteen publications reported data from 15 studies. All but two studies were rated as low quality studies. Interventions included home visiting programmes, complex community programmes, residential treatments, and online interventions. Interventions targeted diverse areas, with parenting skills and understanding the impact of mental illness on parenting most frequently addressed. Both parent and child-related outcomes improved, but children were only assessed via observers and follow-up times were short.

CONCLUSIONS

Interventions were diverse with respect to their nature and effectiveness. Future interventions should combine different intervention strategies to target multiple areas in a flexible manner. The addition of positively focussed and resource-oriented components should be investigated. Trials should include direct assessments of both parents and children, outcomes that are relevant from a public health perspective, and establish the long-term effects ideally until children have reached 18 years of age.

History of childhood sexual abuse and risk of prenatal and postpartum depression or depressive symptoms: an epidemiologic review

The objective of this review is to summarize the literature (and to the extent possible, report the magnitude and direction of the association) concerning history of childhood sexual abuse (CSA) and depression or depressive symptoms among pregnant and postpartum women. Publications were identified through literature searches of seven databases (PubMed, EMBASE, PyscINFO, CINAHL, Web of Science, BIOSIS, and Science Direct) using keywords including "child abuse," "depression," "pregnancy," "prenatal," "pregnancy," and "postpartum." The literature search yielded seven eligible studies on the prenatal period and another seven studies on the postpartum period. All but one prenatal study observed statistically significant positive associations of CSA with depression or depressive symptoms during pregnancy. Findings on the association of CSA with postpartum depression or depressive symptoms were inconsistent; pooled unadjusted and adjusted odds ratios were 1.82 (95 % confidence interval (CI) 0.92, 3.60) and 1.20 (95 % CI 0.81, 1.76). In sum, findings suggest a positive association of history of CSA with depression and depressive symptoms in the prenatal period. Findings on the postpartum period were inconsistent. Clinical and public health implications of evidence from the available literature are discussed, as are desirable study design characteristics of future research.

A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression

BACKGROUND

Cognitive behavioral therapy (CBT) is an empirically supported treatment for treating and preventing depression that has been widely studied in perinatal populations. Previous meta-analytic reviews of CBT interventions in this population have not investigated potential moderators of treatment efficacy specific to this type of therapy.

METHOD

Forty randomized and quasi-randomized controlled trials assessing the efficacy of CBT during pregnancy and the first year postpartum were included in the meta-analyses. Change in depressive symptoms from pre-treatment to post-treatment was assessed in both treatment and prevention trials, and the difference in prevalence of postpartum depressive episodes was assessed in prevention trials. Characteristics of included studies, interventions and samples were assessed as potential moderators of effect sizes.

RESULTS

CBT interventions resulted in significant reductions in depressive symptoms compared to control conditions in both treatment and prevention studies. In prevention studies, individuals who received CBT had significantly lower rates of postpartum depressive episodes compared to control conditions. In both treatment and prevention trials, interventions initiated during the postpartum period were more effective than antenatal interventions. In prevention trials, individually-administered treatments were more effective than group interventions and greater reductions in depressive symptoms were found in studies that included higher proportions of nonwhite, single, and multiparous participants.

LIMITATIONS

The methodological quality of included studies varied widely among studies eligible for inclusion in the meta-analysis.

CONCLUSIONS

There is strong evidence that CBT interventions are effective for treating and preventing depression during the perinatal period. Further methodologically rigorous studies are needed to further investigate potential moderators of treatment efficacy.

Intranasal adminsitration of oxytocin in postnatal depression: implications for psychodynamic psychotherapy from a randomized double-blind pilot study

Oxytocin is a neuropeptide that is active in the central nervous system and is generally considered to be involved in prosocial behaviors and feelings. In light of its documented positive effect on maternal behavior, we designed a study to ascertain whether oxytocin exerts any therapeutic effects on depressive symptoms in women affected by maternal postnatal depression. A group of 16 mothers were recruited in a randomized double-blind study: the women agreed to take part in a brief course of psychoanalytic psychotherapy (12 sessions, once a week) while also being administered, during the 12-weeks period, a daily dose of intranasal oxytocin (or a placebo). The pre-treatment evaluation also included a personality assessment of the major primary-process emotional command systems described by Panksepp () and a semi-quantitative assessment by the therapist of the mother's depressive symptoms and of her personality. No significant effect on depressive symptomatology was found following the administration of oxytocin (as compared to a placebo) during the period of psychotherapy. Nevertheless, a personality trait evaluation of the mothers, conducted in our overall sample group, showed a decrease in the narcissistic trait only within the group who took oxytocin. The depressive (dysphoric) trait was in fact significantly affected by psychotherapy (this effect was only present in the placebo group so it may reflect a positive placebo effect enhancing the favorable influence of psychotherapy on depressive symptoms) but not in the presence of oxytocin. Therefore, the neuropeptide would appear to play some role in the modulation of cerebral functions involved in the self-centered (narcissistic) dimension of the suffering that can occur with postnatal depression. Based on these results, there was support for our hypothesis that what is generally defined as postnatal depression may include disturbances of narcissistic affective balance, and oxytocin supplementation can counteract that type of affective disturbance. The resulting improvements in well-being, reflected in better self-centering in post-partuent mothers, may in turn facilitate better interpersonal acceptance of (and interactions with) the child and thereby, improved recognition of the child's needs.

The relationship between maternal attitudes and symptoms of depression and anxiety among pregnant and postpartum first-time mothers

Two studies examined the relationship between maternal attitudes and symptoms of depression and anxiety during pregnancy and the early postpartum period. In the first study, a measure of maternal attitudes, the Attitudes Toward Motherhood Scale (AToM), was developed and validated in a sample of first-time mothers. The AToM was found to have good internal reliability and convergent validity with cognitive biases and an existing measure of maternal attitudes. Exploratory and confirmatory factor analyses determined that the measure comprises three correlated factors: beliefs about others' judgments, beliefs about maternal responsibility, and maternal role idealization. In the second study, we used the AToM to assess the relationship between maternal attitudes and other psychological variables. The factor structure of the measure was confirmed. Maternal attitudes predicted symptoms of depression and anxiety, and these attitudes had incremental predictive validity over general cognitive biases and interpersonal risk factors. Overall, the results of these studies suggest that maternal attitudes are related to psychological distress among first-time mothers during the transition to parenthood and may provide a useful means of identifying women who may benefit from intervention during the perinatal period.

Pharmacotherapy of postpartum depression: an update

INTRODUCTION

Postpartum depression (PPD) is a common and serious illness that affects up to 14% of women in the first month after childbirth. We present an update on the pharmacologic treatment of PPD, although there continues to be a lack of large, randomized controlled trials (RCTs).

AREAS COVERED

A review of the literature on the use of antidepressants, hormonal supplements and omega-3 fatty acids for the prevention and the treatment of PPD published since the original review in 2009 and the authors' opinion on the current status of the pharmacological treatment of PPD are covered. An electronic search was performed by using PubMed, Medline and PsychINFO. Inclusion criteria were: i) empirical articles in peer-reviewed English-language journals; ii) well-validated measures of depression; and iii) a uniform scoring system for depression among the sample.

EXPERT OPINION

Since the last Expert Opinion review, four antidepressant treatment studies and one prevention study of PPD have been published. Six RCTs evaluating the use of omega-3 fatty acids (four for prevention and two for treatment) have been published. There continues to be lack of data regarding the pharmacotherapy of PPD. However, serotonin reuptake inhibitors should be considered first-line for women with PPD after it has been determined that the proper diagnosis is not bipolar disorder. It is important to individualize treatment for women with PPD and consider the risks and benefits of treatment while breastfeeding.