Maternal antenatal depression and infant disorganized attachment at 12 months

Antenatal depression and offspring health outcomes

Background

Depression is the most common mental disorder during pregnancy, with prevalence rates between 4% and 20%. The objective of this review was to synthesize the literature on the association between antenatal depression and offspring birth outcomes, as well as developmental, behavioral, and psychiatric outcomes.

Methods

A search of PubMed, Cochrane, and Medline databases was conducted for articles published until December 2017. Articles focusing on the effects of antenatal depression on the offspring were selected to be reviewed. Reference lists of all studies were examined for any missed articles. A total of 32 articles were included in this review.

Results

Antenatal depression is associated with preterm birth, excessive infant crying, and offspring mental health problems. Untreated antenatal depression is strongly associated with adverse effects on the infant nervous system.

Conclusion

Antenatal depression increases the likelihood of poor offspring health outcomes. Research should investigate whether medication use confounds this relationship.

Widening the lens on family processes and the development of parent-child attachment relationships

This commentary addresses the research conducted by McConnachie et al. (this issue) on attachment in gay father families, lesbian mother families, and heterosexual parent families. Strengths of the research included the inclusion of different family constellations, the focus on between-family and within-family differences, the longitudinal research design, and the age-appropriate assessment of attachment. Some limitations noted included the lack of control for age at adoption in analyses, the lack of information on parenting processes and parental mental health in the formation of attachment, and questions about information obtained from parent reports of children's prior caregiving histories.

Associations between broader autism phenotype (BAP) and maternal attachment are moderated by maternal postpartum depression when infants are one month old: A prospective study of the Japan environment & children's study

BACKGROUND

Broader autism phenotype (BAP) refers to the expression of behavioral and cognitive dispositions similar to autism spectrum disorder. The present study investigated whether mothers' BAP was prospectively associated with maternal attachment, and if postpartum depression modified this association.

METHODS

The Japan Environment and Children's Study (JECS) is a national and government-funded birth cohort study that began in January 2011. Among the 103,099 mothers enrolled, 87,369 mothers without a history of depression were included in the analysis. Self-administered questionnaires were used. These included: the Japanese version of the Autism Spectrum Quotient, the Mother to Infant Bonding Scale, and the Edinburgh Postnatal Depression Scale. Logistic regression analyses were performed.

RESULTS

The BAP during the second or third trimester of pregnancy was linearly associated with an increased risk of postpartum depression and insecure maternal attachment when infants were one month old (p for trend < 0.001), after adjusting for confounding variables. When stratified by postpartum depression, among the BAP subscales, deficiencies in social skills and communication were associated with an increased risk of insecure maternal attachment in mothers without postpartum depression. The relationships between the BAP subscales and maternal attachment were attenuated among mothers with postpartum depression.

LIMITATIONS

Only five items of the Mother to Infant Bonding Scale were used in the present study, and thus the results should be interpreted with caution.

CONCLUSIONS

Mothers' BAP was predictive of insecure maternal attachment toward their infant. Postpartum depression partially moderated the associations between mothers' BAP and insecure maternal attachment.

Expression of inflammatory markers in women with perinatal depressive symptoms

Perinatal depression affects 10-20% of women and is associated with poor outcomes for mother and child. Inflammation is associated with depression in non-pregnant adults. Perinatal depression and inflammation in pregnancy are independently associated with morbidities including obesity, gestational diabetes, preeclampsia, and preterm birth. The role of inflammation in perinatal depression has received little attention. We hypothesized an association between self-reported perinatal depressive symptoms and serum inflammatory biomarkers TNF-α, IL-6, IL-1β, and CRP. 110 healthy gravidas were recruited in third trimester from an academic medical center, with a baseline study visit at a mean of 32.5 (SD ± 1.8) weeks gestational age. Sixty-three participants completed the Edinburgh Postnatal Depression Scale (EPDS) and provided demographic information and serum samples upon enrollment and at 3 and 6 months postpartum. Serum inflammatory markers were quantified by multiplex array. Multiple linear mixed effects models were used to evaluate trends of biomarkers with the EPDS score in the third trimester of pregnancy and the postpartum period. Elevated serum TNF-α was associated with lower EPDS total score (β = - 0.90, p = 0.046) after adjusting for demographics and medication use. In contrast, IL-6, CRP, and IL-1β did not demonstrate statistically significant associations with depressive symptoms by the EPDS in either crude or adjusted models. Study findings showed no association or an inverse (TNF-α) association between inflammatory markers and perinatal depressive symptoms. Relevant literature evaluating a role for inflammation in depression in the unique context of pregnancy is both limited and inconsistent, and further exploration is merited.

Alterations in Resting-State Networks Following In Utero Selective Serotonin Reuptake Inhibitor Exposure in the Neonatal Brain

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat depression during pregnancy. SSRIs cross the placenta, inhibit serotonin reuptake, and thereby are thought to alter central fetal serotonin signaling. Both prenatal maternal mood disturbances and in utero SSRI exposure have been associated with altered fetal and infant behavior. Resting-state functional magnetic resonance imaging has identified resting-state networks (RSNs) in newborns, reflecting functional capacity of auditory and visual networks and providing opportunities to examine early experiences effects on neurodevelopment. We sought to examine the effect of in utero SSRI exposure on neonatal RSN functional organization. We hypothesized that prenatal SSRI exposure would be associated with alterations in neonatal RSNs compared with healthy control infants and infants exposed to mothers with depression.

METHODS

Clinician-rated Hamilton Depression Rating Scale and self-reported Pregnancy Experiences Scale were completed during the third trimester. Control (n = 17), maternal depression-exposed (Hamilton Depression Rating Scale ≥8 without SSRI exposure, n = 16), and SSRI-exposed (n = 20) 6-day-old neonates underwent resting-state functional magnetic resonance imaging. Independent component analysis was used as a data-driven approach to extract 22 RSNs.

RESULTS

SSRI-exposed neonates had higher connectivity in a putative auditory RSN compared with depressed-only (p = .01) and control (p = .02) infants (corrected for multiple comparisons), controlling for sex, age at the magnetic resonance imaging, and Pregnancy Experiences Scale score.

CONCLUSIONS

Hyperconnectivity in auditory RSN in neonates with in utero SSRI exposure relative to neonates of depressed but not pharmacologically treated mothers and control infants may offer an insight into the functional organization origins of shifts in language perception and altered language development, previously reported in infants and children with prenatal SSRI exposure.

The Neurobiology of Attachment: From Infancy to Clinical Outcomes

Attachment theory was developed by John Bowlby in the 1950s. He defined attachment as a specific neurobiological system that resulted in the infant connecting to the primary caretaker in such a way to create an inner working model of relationships that continues throughout life and affects the future mental health and physical health of the infant. Given the significance of this inner working model, there has been a tremendous amount of research done in animals as well as humans to better understand the neurobiology. In this article the neurobiology of early development will be outlined with respect to the formation of attachment. This article will review what we have begun to understand as the neurobiology of attachment and will describe how the relationship with the primary caretaker affects the infant in a way leading to neurobiological changes that later in life affect emotional responses, reward, and perception difficulties that we recognize as psychiatric illness and medical morbidity.

Risk Factors for Depression: An Autobiographical Review

I have been given a priceless opportunity to reflect on my career in the remarkably productive field of risk factors for depression. Psychological research on depression exploded in the early years of my work. I try to give an account of the choices and challenges, and reflect on the influences, some calculated and some serendipitous, that determined the paths I have followed. I focus mostly on the robust depression risk factors that have influenced my research, including dysfunctional cognitions, stressful life events and circumstances, parental depression, interpersonal dysfunction, and being female, and I cover some of what I did but also the influential work of others. This is a selective review of depression research in the past 40 or so years, noting some of the big developments that set the stage for the remarkable activity that continues today. In the conclusion, there is a brief statement of aspirations for future developments in our field.

Right from the start: protocol for a pilot study for a randomised trial of the New Baby Programme for improving outcomes for children born to socially vulnerable mothers

BACKGROUND

Children born to mothers who experience social complexity (e.g. substance misuse, intimate partner violence, mental ill health, a history of maltreatment) are at increased risk for a range of adverse outcomes at birth and during development. Home visiting programmes have been advocated as a strategy for improving outcomes for disadvantaged mothers and children, such as the Nurse-Family Partnership for young, socially disadvantaged first-time mothers. However, no evidence-based programme is available for multiparous women or older first-time mothers. The New Baby Programme was developed in Northern Ireland. It augments the universal health visiting service available in the UK with a content designed to promote maternal health and well-being in pregnancy, maximise secure attachments of children and parents and enhance sensitive parenting and infant cognitive development.

METHODS/DESIGN

This pilot study is designed to investigate whether it is possible to recruit and retain socially vulnerable mothers in a randomised trial that compares the effects of the New Baby Programme with standard antenatal and postnatal care. Feasibility issues include the referral/recruitment pathway (including inclusion and exclusion criteria), the consent and randomisation, the ability to maintain researcher blinding, the acceptability of the intervention to participants, and the feasibility and acceptability of the outcome measures. The results of the study will inform a definitive phase-3 RCT.

DISCUSSION

Trials of complex social interventions often encounter challenges that lead to the trial being abandoned (e.g. because of problems in recruitment) or present considerable analytic challenges relating to dropout, attrition and bias. This pilot study aims to maximise the chances of successful implementation.

TRIAL REGISTRATION

ISRCTN35456296 retrospectively registered.

Association between maternal depression and maternal sensitivity from birth to 12 months: a meta-analysis

Maternal sensitivity plays a central role in shaping children's development across a number of domains, and may be disrupted by depression. The current meta-analysis quantified the magnitude of the association between depression and maternal sensitivity, defined broadly as timely, contingent, and appropriate responding to infants' cues, from birth to 12 months. Across k = 48 studies and n = 4,934 mother-infant dyads, the aggregate effect size between depression and maternal sensitivity was r = -.16, p < .0001, indicating that mothers with higher depression levels were less sensitive than mothers with lower depression levels. Studies that compared a depressed group with a nondepressed/control group had larger effect sizes (r = -.35, p < .0001) than studies that examined depression within a single sample of either unselected cases or clinical-only cases (r = -.11, p < .001), suggesting that clinical levels of depression may pose a particular threat to sensitive parenting. Clinical implications (e.g. screening, prevention) are discussed.

Developmental cascade effects of interpersonal psychotherapy for depressed mothers: Longitudinal associations with toddler attachment, temperament, and maternal parenting efficacy

Using a developmental cascades framework, the current study investigated whether treating maternal depression via interpersonal psychotherapy (IPT) may lead to more widespread positive adaptation for offspring and mothers including benefits to toddler attachment and temperament, and maternal parenting self-efficacy. The participants (N = 125 mother-child dyads; mean mother age at baseline = 25.43 years; 54.4% of mothers were African American; mean offspring age at baseline = 13.23 months) were from a randomized controlled trial of IPT for a sample of racially and ethnically diverse, socioeconomically disadvantaged mothers of infants. Mothers were randomized to IPT (n = 97) or an enhanced community standard control group (n = 28). The results of complier average causal effect modeling showed that engagement with IPT led to significant decreases in maternal depressive symptoms at posttreatment. Moreover, reductions in maternal depression posttreatment were associated with less toddler disorganized attachment characteristics, more adaptive maternal perceptions of toddler temperament, and improved maternal parenting efficacy 8 months following the completion of treatment. Our findings contribute to the emerging literature documenting the potential benefits to children of successfully treating maternal depression. Alleviating maternal depression appears to initiate a cascade of positive adaptation among both mothers and offspring, which may alter the well-documented risk trajectory for offspring of depressed mothers.

Fathering moderates the effects of maternal depression on the family process

Maternal depression negatively impacts children's development, yet few studies have focused on fathering and the family process in cases of maternal depression. A community cohort of married/cohabitating women was recruited on the second postbirth day (N = 1,983) and maternal depression repeatedly assessed across the first year and again at 6 years to form two cohorts: mothers chronically depressed from birth to 6 (N = 46) and nondepressed controls (N = 103). At 6 years, mother–child, father–child, and family interactions were observed. In families of depressed mothers, both mother and father exhibited lower sensitivity and higher intrusiveness, and children displayed lower social engagement during interactions with mother and father. Fathering moderated the effects of maternal depression on the family process. When fathers showed low sensitivity, high intrusiveness, and provided little opportunities for child social engagement, the family process was less cohesive, implying a decrease in the family's harmonious, warm, and collaborative style. However, in cases of high father sensitivity, low intrusiveness, and increased child engagement, the family process was unaffected by maternal depression. Findings describe both comparability and compensatory mechanisms in the effects of fathering on family life when maternal care is deficient, highlight the buffering role of fathers, and underscore the importance of father-focused interventions when mothers are depressed.

Fewer self-reported depressive symptoms in young adults exposed to maternal depressed mood during pregnancy

BACKGROUND

Depressed mood is prevalent during pregnancy, with accumulating evidence suggesting an impact on developmental outcome in the offspring. However, the long-term effects of prenatal maternal depression regarding internalizing psychopathology in the offspring are as yet unclear.

METHODS

As part of an ongoing epidemiological cohort study, prenatal maternal depressed mood was assessed at the child's age of 3 months. In a sample of n=307 offspring, depressive symptoms were obtained via questionnaire at the ages of 19, 22, 23 and 25 years. At age 25 years, diagnoses of depressive disorder were obtained using a diagnostic interview. In a subsample of currently healthy participants, voxel-based morphometry was conducted and amygdala volume was assessed.

RESULTS

In n=85 young adults exposed to prenatal maternal depressed mood, no significantly higher risk for a diagnosis of depressive disorder was observed. However, they reported significantly lower levels of depressive symptoms. This association was especially pronounced when prenatal maternal depressed mood was present during the first trimester of pregnancy and when maternal mood was depressed pre- as well as postnatally. At an uncorrected level only, prenatal maternal depressed mood was associated with decreased amygdala volume.

LIMITATIONS

Prenatal maternal depressed mood was not assessed during pregnancy, but shortly after childbirth. No diagnoses of maternal clinical depression during pregnancy were available.

CONCLUSIONS

Self-reported depressive symptoms do not imply increased, but rather decreased symptom levels in young adults who were exposed to prenatal maternal depressed mood. A long-term perspective may be important when considering consequences of prenatal risk factors.

Developmental Considerations in the Origins of Object Relations: Implications for Normative Development and Clinical Practice

While previous writers have considered the possibility of pre-object phases of psychic development, their offerings have tended to focus on its conceptualization and implications for psychopathology and psychoanalytic care. The purpose of this paper is to extend some of these ideas by proposing a developmental model that includes a pre-object phase of normal psychic development within an object relations framework and by discussing how this model might further inform our understanding of psychopathology associated with early development and its analytic treatment.

A Systematic Review of the Safety of Electroconvulsive Therapy Use During the First Trimester of Pregnancy

OBJECTIVES

Because of the lack of focus on the safety of electroconvulsive therapy (ECT) during the first trimester of pregnancy in current literature, we set out to assess the safety of ECT use during this vital period of fetal development.

METHODS

A systematic review was conducted, and a case where ECT was employed during the first trimester was presented. Cochrane Library, Ovid MEDLINE, PsycINFO, and PubMed were independently searched by 2 authors using the following search terms: "ECT," "electroconvulsive therapy," "electroshock" combined with "pregnancy," "first trimester of pregnancy," and "teratogenicity."

RESULTS

Of the 97 articles reviewed, 13 met inclusion criteria. We identified 32 first-trimester patients as cases or case series. Adverse outcomes, including miscarriage with previous vaginal bleeding, vaginal bleeding, self-limited abdominal pain, and self-limited fetal spasms, were observed. We added 1 case of a pregnant patient at approximately 9 weeks gestation who experienced a threatened abortion after the administration of ECT.

CONCLUSIONS

Although the data are limited, they suggest that ECT is relatively safe when administered during the first trimester of pregnancy. The possible adverse consequences of ECT during the first trimester of pregnancy should be carefully weighed against the potential benefits of ECT on untreated mental illness.

Infant EEG and temperament negative affectivity: Coherence of vulnerabilities to mothers' perinatal depression

Associations between infants' frontal EEG asymmetry and temperamental negative affectivity (NA) across infants' first year of life and the potential moderating role of maternal prenatal depressive symptoms were examined prospectively in infants (n = 242) of mothers at elevated risk for perinatal depression. In predicting EEG, in the context of high prenatal depressive symptoms, infant NA and frontal EEG asymmetry were negatively associated at 3 months of age and positively associated by 12 months of age. By contrast, for low depression mothers, infant NA and EEG were not significantly associated at any age. Postnatal depressive symptoms did not add significantly to the models. Dose of infants' exposure to maternal depression mattered: infants exposed either pre- or postnatally shifted from a positive association at 3 months to a negative association at 12 months; those exposed both pre- and postnatally shifted from a negative association at 3 months to a positive association at 12 months. Prenatal relative to postnatal exposure did not matter for patterns of association between NA and EEG. The findings highlight the importance of exploring how vulnerabilities at two levels of analysis, behavioral and psychophysiological, co-occur over the course of infancy and in the context of mothers' depressive symptomatology.

Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment

PURPOSE OF THE REVIEW

Opioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population.

RECENT FINDINGS

We review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal ("detoxification") is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad.

SUMMARY

Further research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.

An Internet-Based Intervention (Mamma Mia) for Postpartum Depression: Mapping the Development from Theory to Practice

BACKGROUND

As much as 10-15% of new mothers experience depression postpartum. An Internet-based intervention (Mamma Mia) was developed with the primary aims of preventing depressive symptoms and enhancing subjective well-being among pregnant and postpartum women. A secondary aim of Mamma Mia was to ease the transition of becoming a mother by providing knowledge, techniques, and support during pregnancy and after birth.

OBJECTIVE

The aim of the paper is to provide a systematic and comprehensive description of the intervention rationale and the development of Mamma Mia.

METHODS

For this purpose, we used the intervention mapping (IM) protocol as descriptive tool, which consists of the following 6 steps: (1) a needs assessment, (2) definition of change objectives, (3) selection of theoretical methods and practical strategies, (4) development of program components, (5) planning adoption and implementation, and (6) planning evaluation.

RESULTS

Mamma Mia is a fully automated Internet intervention available for computers, tablets, and smartphones, intended for individual use by the mother. It starts in gestational week 18-24 and lasts up to when the baby becomes 6 months old. This intervention applies a tunneled design to guide the woman through the program in a step-by-step fashion in accordance with the psychological preparations of becoming a mother. The intervention is delivered by email and interactive websites, combining text, pictures, prerecorded audio files, and user input. It targets risk and protective factors for postpartum depression such as prepartum and postpartum attachment, couple satisfaction, social support, and subjective well-being, as identified in the needs assessment. The plan is to implement Mamma Mia directly to users and as part of ordinary services at well-baby clinics, and to evaluate the effectiveness of Mamma Mia in a randomized controlled trial and assess users' experiences with the program.

CONCLUSIONS

The IM of Mamma Mia has made clear the rationale for the intervention, and linked theories and empirical evidence to the contents and materials of the program. This meets the recent calls for intervention descriptions and may inform future studies, development of interventions, and systematic reviews.

Untreated depression during pregnancy: Short- and long-term effects in offspring. A systematic review

Aim of this systematic review is to assess short- and long-lasting effects of antenatal exposure to untreated maternal depressive symptoms. Pertinent articles were identified through combined searches of Science.gov, Cochrane library, and PubMed databases (through August 2015). Forty-three, selected articles revealed that untreated gestational depression and even depressive symptoms during pregnancy may have untoward effects on the developing fetus (hyperactivity, irregular fetal heart rate), newborns (increased cortisol and norepinephrine levels, decreased dopamine levels, altered EEG patterns, reduced vagal tone, stress/depressive-like behaviors, and increased rates of premature deaths and neonatal intensive care unit admission), and children (increased salivary cortisol levels, internalizing and externalizing problems, and central adiposity). During adolescence, an independent association exists between maternal antenatal mood symptoms and a slight increase in criminal behaviors. In contrast, the relationship between gestational depression and increased risks of prematurity and low birth weight remains controversial. Given this background, when making clinical decisions, clinicians should weigh the growing evidences suggesting the detrimental and prolonged effects in offspring of untreated antenatal depression and depressive symptoms during pregnancy against the known and emerging concerns associated with in utero exposure to antidepressants.

First validation of a Spanish-translated version of the Edinburgh postnatal depression scale (EPDS) for use in pregnant women. A Chilean study

The objective of the study was to evaluate the psychometric properties of the Edinburg Postnatal Depression Scale (EPDS) to detect depression during pregnancy in Chile. The EPDS was applied to a sample of 111 pregnant women, who were attending an antenatal appointment in primary care centers. The Beck Depression Inventory (BDI-I) was used to assess the convergent validity, and the Depressive Episode module of the MINI was used to identify cases. The factor analysis showed that there was a good fit, with a factor model that explains 57.6 % of the total variance. There was a high degree of internal consistency (Cronbach's α = 0.914) and good convergent validity with the BDI-I (rho = 0.850, p < 0.001). The EPDS was capable of differentiating cases of depression from non-cases. The best cutoff point was between 12 and 13, corresponding to an overall accuracy of 87.4 %. The questionnaire has good psychometric properties and can be useful for detecting cases of depression during pregnancy.

Maternal cortisol during pregnancy is related to infant cardiac vagal control

BACKGROUND

Prenatal exposure to maternal psychological distress and glucocorticoids result in neurobiological adaptations within the fetus that increase risk for developing exaggerated emotional, behavioral, and stress responses to novelty and challenges in childhood. The current study investigated the influence of maternal depressed mood and cortisol during pregnancy on infant cardiac vagal control (CVC) to standardized laboratory challenge tasks.

METHODS

The sample comprised 194 women and their infants. Maternal reports of depressed mood and salivary cortisol were assessed at 14 and 32 weeks gestational age. Linear regression was used to examine associations between maternal measures during early and late pregnancy, and infant CVC indexed via respiratory sinus arrhythmia (RSA) at rest and in response to laboratory tasks designed to elicit frustration when infants were 6 months of age. It was hypothesized that maternal depressed mood and cortisol would be associated with lower basal RSA and smaller decreases in RSA from baseline to challenge.

RESULTS

A significant decrease in infant RSA from baseline to frustration tasks indicated that laboratory tasks elicited a reliable decrease in RSA from baseline to frustration among infants which is characterized by reduction in vagal efferent activity on the heart in response to challenge. Higher maternal cortisol, but not depressed mood, was associated with lower basal RSA and greater decrease in RSA from baseline to frustration. Associations between maternal cortisol and infant basal RSA were observed for both early and late pregnancy whereas the associations between prenatal cortisol and decrease in RSA from baseline to frustration were observed for early, but not late, pregnancy.

CONCLUSIONS

Maternal cortisol during pregnancy was associated with infant CVC at 6-months of age. Such influences may have enduring impacts on the child and important implications for the development of physical and mental health outcomes.

Peripartum depression and anxiety as an integrative cross domain target for psychiatric preventative measures

Exposure to high levels of early life stress has been identified as a potent risk factor for neurodevelopmental delays in infants, behavioral problems and autism in children, but also for several psychiatric illnesses in adulthood, such as depression, anxiety, autism, and posttraumatic stress disorder. Despite having robust adverse effects on both mother and infant, the pathophysiology of peripartum depression and anxiety are poorly understood. The objective of this review is to highlight the advantages of using an integrated approach addressing several behavioral domains in both animal and clinical studies of peripartum depression and anxiety. It is postulated that a greater focus on integrated cross domain studies will lead to advances in treatments and preventative measures for several disorders associated with peripartum depression and anxiety.

Effects of perinatal mental disorders on the fetus and child

Perinatal mental disorders are associated with increased risk of psychological and developmental disturbances in children. However, these disturbances are not inevitable. In this Series paper, we summarise evidence for associations between parental disorders and offspring outcomes from fetal development to adolescence in high-income, middle-income, and low-income countries. We assess evidence for mechanisms underlying transmission of disturbance, the role of mediating variables (underlying links between parent psychopathology and offspring outcomes) and possible moderators (which change the strength of any association), and focus on factors that are potentially modifiable, including parenting quality, social (including partner) and material support, and duration of the parental disorder. We review research of interventions, which are mostly about maternal depression, and emphasise the need to both treat the parent's disorder and help with associated caregiving difficulties. We conclude with policy implications and underline the need for early identification of those parents at high risk and for more early interventions and prevention research, especially in socioeconomically disadvantaged populations and low-income countries.

Social support and self-esteem as mediators between stress and antepartum depressive symptoms in rural pregnant women

The purpose of this secondary analysis was to determine whether satisfaction with social support and self-esteem mediated the relationship between antepartum stress and depressive symptoms in women attending prenatal clinics in a rural Southeastern community (N = 318). Path analysis with linear regression indicated that the relationship between antepartum stress and depressive symptoms was partially mediated by higher levels of the internal resources of satisfaction with social support and self-esteem. Self-esteem had a greater influence on the relationship between antepartum stress and depressive symptoms than did satisfaction with social support. These findings suggest further study to determine whether developing culturally tailored interventions that emphasize stress reduction activities in addition to enhancing self-esteem and increasing satisfaction with social support can decrease the burden of antepartum depressive symptoms in rural low-income women.

Assessing the Impact of Parental Depressive Symptoms on Offspring Temperament and Development in Infancy

The study prospectively followed 135 women during their pregnancy and their offspring till 6 months of age, to examine the roles of maternal and paternal depression during pregnancy on offspring neurobehavioral development as measured by their early temperament. Maternal and paternal depression statuses were ascertained during the third trimester, and infant temperament was evaluated at 6 months, via mothers self-report. Multivariable general linear model was used to assess 1) the main effects of maternal and paternal depression on infant temperament and 2) the interaction effect between maternal and paternal depression on infant temperament. Results show that maternal depression, but not paternal depression, was directly associated with greater neurobehavioral impairment in offspring as evident by more difficult temperament, including lower Smiling and Laughter (p= .006), lower Soothability (p= .02), elevated Sadness (p= .04) and lower Vocal Reactivity (p= .001). Moreover, only in the presence of maternal depression, was paternal depression significantly associated with signs of offspring neurobehavioral impairment, including lower Smiling and Laughter (p= .01) lower High Pleasure Seeking (p= .03), lower Soothability (p= .05), lower Cuddliness (p= .05) and lower Vocal Reactivity (p< .0001). These findings suggest that maternal, but not paternal, depression was directly associated with infant neurobehavioral impairment. Significant interaction effect suggests that in the presence of maternal depression, paternal depression amplifies its negative valence on infant neurobehavioral development. Providing intervention services not only for depressed mothers but also their partners during pregnancy may prove to be an effective prevention strategy for suboptimal neurobehavioral development in offspring.

Depression and anxiety among high-risk obstetric inpatients

OBJECTIVE

To assess the following among women hospitalized antenatally due to high-risk pregnancies: (1) rates of depression symptoms and anxiety symptoms, (2) changes in depression symptoms and anxiety symptoms and, (3) rates of mental health treatment.

METHODS

Sixty-two participants hospitalized for high-risk obstetrical complications completed the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder 7-item scale (GAD-7) and Short-Form 12 weekly until delivery or discharge, and once postpartum.

RESULTS

Average length of total hospital stay was 8.3 ± 7.6 days for women who completed an initial admission survey (n = 62) and 16.3 ± 8.9 (n = 34), 25.4 ± 10.2 (n = 17) and 35 ± 10.9 days (n = 9) for those who completed 2, 3 and 4 surveys, respectively. EPDS was ≥ 10 in 27% (n=17) and GAD-7 was ≥ 10 in 13% (n = 8) of participants at initial survey. Mean anxiety (4.2 ± 6.5 vs. 5.2 ± 5.1, p = .011) and depression (4.4 ± 5.6 vs. 6.9 ± 4.8, p = .011) scores were lower postpartum compared to initial survey. Past mental health diagnosis predicted depression symptoms [odds ratio (OR) = 4.54; 95% confidence interval (CI) 1.91-7.17] and anxiety symptoms (OR = 5.95; 95% CI 3.04-8.86) at initial survey; however, 21% (n = 10) with no diagnostic history had EPDS ≥ 10. Five percent (n = 3) received mental health treatment during pregnancy.

CONCLUSION

Hospitalized high-risk obstetrical patients may commonly experience depression symptoms and/or anxiety symptoms and not receive treatment. A history of mental health treatment or diagnosis was associated with depression symptoms or anxiety symptoms in pregnancy. Of women with an EPDS ≥ 10, > 50% did not report a past mental health diagnosis.

Depression and anxiety in Singaporean high-risk pregnancies - prevalence and screening

OBJECTIVE

Data on psychiatric morbidity in high-risk pregnant Singaporean women are limited. This study aimed to establish the prevalence of antenatal depression and anxiety in high-risk pregnancies, compare the prevalence of antenatal depression in high-risk pregnancies vs. pregnancies of unspecified obstetric risk and examine the Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Inventory (STAI) as screening tools for these disorders.

METHOD

Two hundred high-risk pregnant inpatients at a national public maternity hospital were included. Three psychometric assessment tools were used to evaluate all participants: the diagnostic Mini International Neuropsychiatric Interview and the screening EPDS and STAI.

RESULTS

Rates of major depression, minor depression, anxiety disorder (agoraphobia, generalized anxiety disorder, panic disorder), and comorbid depression and anxiety were 11%, 7%, 12.5% and 5%, respectively. Major depression was more prevalent in high-risk pregnancies than in the historical cohort of unspecified obstetric risk (11% versus 4.3%). EPDS (cutoff 8/9) screens well for depression and anxiety in high-risk pregnancies (area under the receiver operating characteristic curve=0.82-0.87).

CONCLUSION

Antenatal depression and anxiety are highly prevalent in a sample of high-risk pregnant Singaporean women. EPDS performs well in screening for depression and anxiety in high-risk pregnant women, with further psychiatric assessment recommended for women with score ≥ 9.