The global prevalence of postpartum psychosis: a systematic review

A pregnant woman who experienced auditory hallucinations concurrent with hyperemesis gravidarum: A case report

We report the case of a pregnant woman who experienced auditory hallucinations only while suffering from hyperemesis gravidarum. To the best of our knowledge, the present report is the first report of a case of obvious auditory hallucinations and hyperemesis gravidarum at the same time in a pregnant woman who had not been diagnosed with any psychiatric disorder. The patient was a 24‐year‐old pregnant woman with no history of psychiatric disorder. Two years prior to this admission, she became pregnant for the first time, and she was admitted to an obstetrics clinic due to severe hyperemesis gravidarum. She developed mild auditory hallucinations at the same time. After she gave birth, the auditory hallucinations disappeared. When she was 24 years old, she became pregnant again. She suffered from severe hyperemesis gravidarum from the early stage of pregnancy. At 20 weeks of pregnancy, she visited the Department of Psychiatry of our hospital for a detailed psychiatric evaluation and treatment because her moderate auditory hallucinations had relapsed. We administered an antipsychotic agent, perospirone, to treat the auditory hallucinations, which disappeared, although the hyperemesis gravidarum persisted until childbirth. After childbirth, perospirone treatment was discontinued, and her auditory hallucinations did not relapse. The auditory hallucinations may have occurred as a result of complicated biological and psychosocial factors. Physicians should carefully evaluate psychotic symptoms, such as auditory hallucinations, not only during the postpartum period but also throughout the course of pregnancy.

The present report is the first report of a case of obvious auditory hallucinations and hyperemesis gravidarum at the same time in a pregnant woman who had not been diagnosed with any psychiatric disorder. We administered an antipsychotic agent, perospirone, to treat the auditory hallucinations, which disappeared, although the hyperemesis gravidarum persisted until childbirth. After childbirth, perospirone treatment was discontinued, and her auditory hallucinations did not relapse.

CE: Postpartum Depression: A Nurse's Guide

ABSTRACT

Despite extensive research, the etiology behind postpartum depression (PPD) remains a mystery. Experts have theorized about various potential risk factors, including hormonal fluctuations, genetics, prior history of depression, low socioeconomic status, adolescent pregnancy, and certain personality traits. This article provides foundational information about PPD, reviewing the risk factors for and the consequences of this mood disorder. Postpartum blues and postpartum psychosis are briefly discussed for context, although they differ from PPD. Screening and treatment options are explained, and nursing implications for practice are presented.

Psychometric Properties of the Perinatal Anxiety Screening Scale Administered to Italian Women in the Perinatal Period

Literature stressed the importance of using valid, reliable measures to assess anxiety in the perinatal period, like the self-rated Perinatal Anxiety Screening Scale (PASS). We aimed to examine the psychometric properties of the Italian PASS version in a sample of Italian women undergoing mental health screening during their third trimester of pregnancy and its diagnostic accuracy in a control perinatal sample of psychiatric outpatients. Sample comprised 289 women aged 33.17 ± 5.08, range 19-46 years, undergoing fetal monitoring during their third trimester of pregnancy, with 49 of them retested 6 months postpartum. Controls were 60 antenatal or postnatal psychiatric outpatients aged 35.71 ± 5.02, range 22-50 years. Groups were assessed through identical self- and clinician-rating scales. Confirmatory Factor Analysis (CFA), Principal Component Analysis (PCA), Pearson's correlations and receiver operating characteristic were conducted for PASS. PCA and CPA confirmed four-factor structure with slight differences from the original version. Construct validity and test-retest reliability were supported. Cut-off was 26. The PASS correlated with principal anxiety scales. Despite small sample size, findings confirm reliability and validity of the Italian PASS version in assessing anxiety symptoms in the perinatal period. Its incorporation in perinatal care will improve future mother and child psychological health.

[Electroconvulsive therapy during the perinatal period: Representations of mental health professionals]

INTRODUCTION

Psychiatric disorders are common in peripartum and are associated with adverse outcomes for mother and fetus. Electroconvulsive therapy (ECT) is one of the most effective and safe options to treat severe mental illness, including during the perinatal period. Nevertheless, it remains underutilized during this period, possibly due to negative representations. Research has been carried out on the representations and attitudes of caregivers towards ECT, but the specificities of these attitudes during peripartum have not been explored.

OBJECTIVES

We aimed to assess the attitudes towards ECT during the peripartum among psychiatrists, nurses, social workers and psychologists. The primary objective was to compare the score of favorability for ECT during peripartum according to the profession. The secondary objective was to highlight other factors involved in the favorability for ECT in peripartum.

METHODS

We investigated mental health professionals' attitudes sending by e-mail an anonymous questionnaire in five hospitals in France. The questionnaire was composed of demographic details, one scale about the attitudes towards ECT (the Questionnaire on Attitudes and Knowledge of ECT (QuAKE)) used in several studies; in this questionnaire, a specific part for perinatal period has been added for our study, both using a Likert scale. The completion time for this online questionnaire was approximately 5 to 7minutes. A score of favorability for ECT in general and in peripartum was established for each participant. These scores represented the percentage of positive responses to favorable items and of negative responses to unfavorable items towards ECT. Comparison of the QuAKE answers with a sample of English caregivers in 2001 has been determined with χ² tests. A Bonferroni correction was applied due to the large number of tests performed. Factors involved in the favorability for ECT have been studied with Pearson correlation, Kruskall-Wallis and Wilcoxon tests.

RESULTS

Two hundred and twenty one professionals (80 psychiatrists, 78 nurses, 19 social workers and 44 psychologists) were included in the study. Their answers to the QuAKE questionnaire were comparable or more favorable to ECT than the English sample answered in 2001. The perinatal part of questionnaire had a good internal consistency (Cronbach coefficient: 0,91). Participants were less favorable to ECT in perinatal period (favorability score: 44.2) than in general (63.6). They more often responded « uncertain » to the perinatal questionnaire (44,9 % against 18.4 % for the ECT in general; W=19931,5; P<0,001). The favorability for ECT in general and during peripartum were statistically associated with profession (psychiatrists were more favorable), specific training and experience in ECT. Gender, perinatal specialization, age, and the number of years in professional service were not associated with favorability for ECT in general and during peripartum in this study.

CONCLUSIONS

In this study, we have found that profession, training and experience in ECT are linked to the attitudes towards ECT, including in the perinatal period. It is necessary to inform professionals about the possibility of prescribing ECT in the perinatal period by training them in the specificities of pregnancy.

Health professional perspectives on an antenatal mental health screening program in a private hospital

BACKGROUND

Perinatal mental ill-health is a global health priority. Mental health screening during pregnancy is a routine part of clinical practice in many public hospital obstetric services across Australia, but implementation in the private hospital system has lagged.

AIMS

This study explored health professionals' perspectives on the Pre-admission Midwife Appointment Program (PMAP), an antenatal mental health screening program at the Mater Hospital, Sydney.

MATERIALS AND METHODS

Nine midwives and three medical specialists participated in focus groups or individual interviews; key themes were determined using thematic qualitative analysis.

RESULTS

Five major themes and three sub-themes were identified: immediate benefits to women (identifying women at risk; referrals to support services; supporting and educating women); enhanced overall quality of care at the hospital; the dilemma of partners attending; factors that make the program successful; and recommendations for improvement.

CONCLUSIONS

Results will inform the implementation of antenatal mental health screening programs at other private hospitals across Australia.

Depression Outcomes From a Fully Integrated Obstetric Mental Health Clinic: A 10-Year Examination

BACKGROUND: A fully integrated Obstetric Mental Health Clinic (OBMHC) was established in 2007 in the rural northwest United States to address perinatal depression. AIMS: The purpose of this mixed methods study was to examine depression outcomes in women receiving outpatient psychiatric services between 2007 and 2017 at a fully integrated OBMHC and to explore patient and obstetric team perceptions of OBMHC experiences. METHOD: A retrospective database study was employed; depression was measured at baseline and follow-up visits using the Edinburgh Postnatal Depression Scale. Descriptive statistics, regression models, and trend analysis were employed to determine effectiveness. A subset of patients participated in telephone interviews; the obstetric team was surveyed regarding perceptions of the service. RESULTS: The sample included 192 women (195 pregnancies). Approximately 72% experienced less depression by the first follow-up visit. Patients taking three or more psychiatric medications attended more OBMHC visits. Trend analysis indicated that women with the highest levels of depression had the best response to the intervention. Three qualitative themes emerged: Safe Place, Mental/Emotional Stability, and Integrated Personalized Approach. Obstetric team members (n = 11) perceived the clinic to be helpful and noted improved access to mental health care. CONCLUSION: OBMHCs can be effective when psychiatric nurses are embedded within an outpatient obstetric service. Improved access, timely services, and patient reassurance can lead to an improved pregnancy experience and reduced depressive symptoms. The longevity of this clinic's experience serves as a role model for other centers to replicate this successful integrated model of care.

Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review

Postpartum psychoses are a severe form of postnatal mood disorders, affecting 1–2 in every 1000 deliveries. These episodes typically present as acute mania or depression with psychosis within the first few weeks of childbirth, which, as life-threatening psychiatric emergencies, can have a significant adverse impact on the mother, baby and wider family. The nosological status of postpartum psychosis remains contentious; however, evidence indicates most episodes to be manifestations of bipolar disorder and a vulnerability to a puerperal trigger. While childbirth appears to be a potent trigger of severe mood disorders, the precise mechanisms by which postpartum psychosis occurs are poorly understood. This review examines the current evidence with respect to potential aetiology and childbirth-related triggers of postpartum psychosis. Findings to date have implicated neurobiological factors, such as hormones, immunological dysregulation, circadian rhythm disruption and genetics, to be important in the pathogenesis of this disorder. Prediction models, informed by prospective cohort studies of high-risk women, are required to identify those at greatest risk of postpartum psychosis.

A new molecular risk pathway for postpartum mood disorders: clues from steroid sulfatase-deficient individuals

Postpartum mood disorders develop shortly after childbirth in a significant proportion of women. These conditions are associated with a range of symptoms including abnormally high or low mood, irritability, cognitive disorganisation, disrupted sleep, hallucinations/delusions, and occasionally suicidal or infanticidal ideation; if not treated promptly, they can substantially impact upon the mother's health, mother-infant bonding, and family dynamics. The biological precipitants of such disorders remain unclear, although large changes in maternal immune and hormonal physiology following childbirth are likely to play a role. Pharmacological therapies for postpartum mood disorders can be effective, but may be associated with side effects, concerns relating to breastfeeding, and teratogenicity risks when used prophylactically. Furthermore, most of the drugs that are used to treat postpartum mood disorders are the same ones that are used to treat mood episodes during non-postpartum periods. A better understanding of the biological factors predisposing to postpartum mood disorders would allow for rational drug development, and the identification of predictive biomarkers to ensure that 'at risk' mothers receive earlier and more effective clinical management. We describe new findings relating to the role of the enzyme steroid sulfatase in maternal postpartum behavioural processes, and discuss how these point to a novel molecular risk pathway underlying postpartum mood disorders. Specifically, we suggest that aberrant steroid hormone-dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important. Testing of this hypothesis might identify novel therapeutic targets and predictive biomarkers.

Maternal Functioning and Depression Scores Improve Significantly With Participation in Visiting Moms® Program

BACKGROUND: Postpartum depression is the most common complication of childbearing can affect the entire family unit. Health professionals must strive to identify and develop effective, feasible solutions for women during this critical period. AIMS: To determine whether postpartum maternal functioning (as measured by the Barkin Index of Maternal Functioning) and depression symptoms (as measured by the Patient Health Questionnaire-9) were improved after participation in the Visiting Moms program. METHOD: Paired data were collected from women at program intake and after completion of the Visiting Moms program. Visiting Moms provides services through eastern and central Massachusetts and was designed to support new mothers throughout the infant's first year of life. The study population was composed of adult women living in the Jewish Family and Children's Services geographic catchment area, who enrolled in Visiting Moms between January 1, 2013, and December 31, 2015. Descriptive statistics were calculated for all 402 women enrolled in this timeframe. Utilizing a pretest/posttest design, paired t tests were performed for the Barkin Index of Maternal Functioning (n = 149) and for the Patient Health Questionnaire-9 (n = 156), where women had complete scores at both intake and completion, to determine the program's potential impact on depressive symptoms and functional status. RESULTS: Functioning and depression scores were significantly improved after participation in the program. CONCLUSIONS: Visiting moms, and similar programs, aimed at delivery of enhanced social support, may be effective in promoting mental and emotional wellness among new mothers who are require additional support in the postpartum period.

Postpartum psychosis and SARS-CoV-2 infection: is there a correlation?

The COVID-19 pandemic has had a negative impact on mental health. Cases of psychosis associated with SARS-CoV-2 infection have been noted. The Women's Mental Health Program at the University of Arkansas for Medical Sciences determined four-fold increase from data from the last 5 years. We propose that the pandemic should be considered a risk factor for postpartum psychosis. Providers should emphasize sleep hygiene and monitor carefully for psychosis in postpartum women.

Psychological Distress, Coping and Perceived Social Support Among Partners of Women with Postpartum Onset Severe Mental Illness (SMI) Admitted to a Mother-Baby Unit

BACKGROUND

The presence of a severe mental illness in the mother during the postpartum period may impact the whole family and specifically have an effect on the health of the spouse. The current study aimed to assess psychological distress, coping, and perceived social support of spouses of women with postpartum onset severe mental illness.

METHODOLOGY

A cross-sectional descriptive research design was used, and 30 spouses of the women admitted to the mother-baby unit (MBU) for psychiatric inpatient care were included in the study. The assessments included sociodemographic details, Kessler psychological distress scale (K10), brief coping orientation to problems experienced scale (brief COPE), and Zimets' multidimensional scale of perceived social support.

RESULTS

Around 50% of the spouses experienced severe psychological distress. Nearly 40% of spouses reported poor coping and 56.7% of spouses had moderate social support from family and friends.

CONCLUSION

The findings indicate the need to address distress and coping in spouses of women with postpartum onset SMI.

Recovery from postpartum psychosis: a systematic review and metasynthesis of women's and families' experiences

Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women's experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted.

Organic vs Stimulant-Induced Psychosis in the Peripartum Period

This is the case of a 30-year-old pregnant female who presented to the medical emergency department with signs and symptoms consistent with a psychotic episode. At the time of presentation, the patient was noted to have paranoia and delusions focused on her current pregnancy. On further evaluation in the emergency department, the patient’s urine toxicology was found to be positive for methamphetamines. Following medical clearance, the patient was admitted for acute inpatient psychiatric stabilization. During hospitalization, her psychosis rapidly resolved with only the use of two emergency treatment injections containing antipsychotic medication. This case presents an interesting differential diagnosis between a brief psychotic disorder with peripartum onset and a substance-induced psychosis, and allows for further discussion in the differentiation and clinical treatment of these diagnoses. 

Maternal personality, social support, and changes in depressive, anxiety, and stress symptoms during pregnancy and after delivery: A prospective-longitudinal study

Background

The role of maternal personality and perceived social support for peripartum changes in psychopathological symptoms remains unresolved.

Methods

In a regional-epidemiological sample of 306 women, depressive, anxiety, and stress symptoms were assessed three times during pregnancy and three times after delivery with the 21-item version of the Depression Anxiety Stress Scale. In pregnancy, the Big Five personality traits and perceived social support were assessed with the short version of the Big Five Inventory and the Social Support Questionnaire.

Results

Multilevel analyses revealed that depressive (b = -0.055) and stress (b = -0.047) symptoms decreased from early to late pregnancy. After delivery, anxiety symptoms were lower (two months postpartum: b = -0.193; four/ 16 months postpartum: b = -0.274), but stress symptoms were higher (two months postpartum: b = 0.468; four/ 16 months postpartum: b = 0.320) than during pregnancy. Across the peripartum period, more conscientious and more extraverted women experienced lower depressive and stress symptoms (b = -0.147 to -0.177), and more emotionally stable women experienced lower depressive, anxiety, and stress symptoms (b = -0.294 to -0.415). More emotionally stable women more strongly increased in anxiety during pregnancy (b = 0.019), and more extraverted women less strongly increased in depression after delivery (b = -0.010). Moreover, peripartum depressive, anxiety, and stress symptoms were lower in women with higher perceived social support (b = -0.225 to -0.308).

Conclusions

Less emotionally stable, less conscientious, and less extraverted women and women with lower perceived social support seem to be at increased risk for peripartum psychopathological symptoms and might thus particularly profit from targeted prevention.

Antipsychotics in Postpartum Psychosis

BACKGROUND

Psychotic episodes in the postpartum period are life-threatening psychiatric emergencies, requiring urgent medical attention and admission to a psychiatric hospital.

AREAS OF UNCERTAINTY

Although the postpartum psychosis (PPP) is the most severe psychiatric disorder associated with parturition, there is little information about what interventions are most effective. Because there are no specific guidelines for the treatment of PPP, the aim of the present review was to examine the available evidence regarding the treatment of PPP.

DATA SOURCES

The PubMed database was searched based on the title and the abstract, using the key words "postpartum psychosis," "postpartum psychosis antipsychotics," "postpartum psychosis treatment," and "postpartum psychosis pharmacotherapy," for both interventional and observational, irrespective of language.

RESULTS

A number of 14 publications met the study criteria, including case reports and case series. The antipsychotics (APs) use included both first generation APs, such as haloperidol and chlorpromazine, and second generation APs, mainly, olanzapine, quetiapine, and risperidone. The most frequently used AP was olanzapine. Olanzapine and quetiapine seem to be the most acceptable during breastfeeding. Proposed treatment algorithms for the successful management of PPP are discussed.

CONCLUSIONS

The existing studies to date do not allow to draw a definitive conclusion regarding which treatment is the most effective or the most adequate. Existing evidence suggests that APs alone or in combination are responsible for sustained remission and that treated PPP has a higher pace of improvement of the mental status, with a rapid discharge from the hospital. Clinical studies to compare the efficacy and safety of different APs in the PPP are needed to provide guidance on treatment interventions.

Machine Learning Models for the Prediction of Postpartum Depression: Application and Comparison Based on a Cohort Study

Background

Postpartum depression (PPD) is a serious public health problem. Building a predictive model for PPD using data during pregnancy can facilitate earlier identification and intervention.

Objective

The aims of this study are to compare the effects of four different machine learning models using data during pregnancy to predict PPD and explore which factors in the model are the most important for PPD prediction.

Methods

Information on the pregnancy period from a cohort of 508 women, including demographics, social environmental factors, and mental health, was used as predictors in the models. The Edinburgh Postnatal Depression Scale score within 42 days after delivery was used as the outcome indicator. Using two feature selection methods (expert consultation and random forest-based filter feature selection [FFS-RF]) and two algorithms (support vector machine [SVM] and random forest [RF]), we developed four different machine learning PPD prediction models and compared their prediction effects.

Results

There was no significant difference in the effectiveness of the two feature selection methods in terms of model prediction performance, but 10 fewer factors were selected with the FFS-RF than with the expert consultation method. The model based on SVM and FFS-RF had the best prediction effects (sensitivity=0.69, area under the curve=0.78). In the feature importance ranking output by the RF algorithm, psychological elasticity, depression during the third trimester, and income level were the most important predictors.

Conclusions

In contrast to the expert consultation method, FFS-RF was important in dimension reduction. When the sample size is small, the SVM algorithm is suitable for predicting PPD. In the prevention of PPD, more attention should be paid to the psychological resilience of mothers.

Managing bipolar disorder during pregnancy and the postpartum period: a critical review of current practice

Introduction: Despite increased interest in the pharmacotherapy of bipolar disorder during pregnancy and the postpartum period, management of the disorder during these critical periods in a woman's life remains challenging.Areas covered: The authors review the effect of pregnancy and the postpartum period on the course of bipolar disorder, describe adverse pregnancy and birth outcomes, and discuss the pharmacotherapy of bipolar disorder during and after pregnancy.Expert opinion: When treating women with bipolar disorder of childbearing age, clinicians should consider the possibility of pregnancy. Pre-conception counseling should be an integral part of the overall plan to manage bipolar disorder during and after pregnancy. Peripartum management of bipolar disorder is challenging and requires balancing of risks associated with the use of drugs and the potentially deleterious effects of untreated bipolar disorder on the fetus/child. Formulation of personalized treatment requires knowledge of both current (episode type, symptom severity, psychiatric comorbidity, and safety concerns) and historical (episode frequency, response to drugs and psychotherapy, and the effect of reproductive events including pregnancy and postpartum period) factors. Close monitoring is essential for early detection and management of mood episodes. Routine safety assessments are necessary to identify women at risk of harming themselves or the newborn.

Adverse childhood experiences and postpartum depression in bipolar disorder

BACKGROUND

Women are particularly vulnerable to recurrence of bipolar disorder (BD) following childbirth. Risk of postpartum psychosis (PP) is especially high, but postpartum depression (PPD) is also common. Adverse childhood experiences (ACEs) have not been associated with PP, but have been associated with PPD in non-bipolar samples. The relationship between ACEs and PPD within BD remains to be investigated. Here, we examined this association in a large, well-defined sample of women with BD.

METHODS

Participants were 575 parous women with DSM-IV BD. Lifetime psychopathology, including perinatal, was assessed via semi-structured interview and case-notes. ACEs, assessed via self-report and case-notes, were compared between women with lifetime PPD (n = 368) and those without a lifetime history of perinatal mood episodes (n = 207).

RESULTS

In univariate analysis exposure to 3 or more ACEs, and to childhood abuse specifically, was significantly associated with PPD (p = 0.026 and 0.041 respectively), but this did not remain significant after adjusting for lifetime number of episodes of depression and parity. Post-hoc analysis revealed more frequent episodes of depression to be associated with both a history of 3 or more ACEs and of childhood abuse.

LIMITATIONS

Limited range of ACEs assessed and potential recall bias.

CONCLUSIONS

Increased frequency of ACEs and particularly childhood abuse was associated with more frequent lifetime episodes of depression, but not specifically episodes with postpartum onset. Understanding factors that mediate the pathway between ACEs and PPD in BD has implications for risk prediction of PPD.

Maternal and infant characteristics associated with maternal opioid overdose in the year following delivery

BACKGROUND AND AIMS

Opioid-related overdose is increasingly linked to pregnancy-associated deaths, but factors associated with postpartum overdose are unknown. We aimed to estimate the strength of the association between maternal and infant characteristics and postpartum opioid-related overdose.

DESIGN

Retrospective cohort study using a linked, population-level data set.

SETTING

Massachusetts, United States.

CONCLUSION

Among women who delivered live infants in Massachusetts, USA between 2012 and 2014, maternal diagnosis of OUD, prior non-fatal overdose, infant diagnosis of NAS and high unscheduled health-care utilization appeared to be positively associated with postpartum opioid overdose. However, more than half of postpartum overdoses in that period were to women without a diagnosis of OUD. Engagement in methadone or buprenorphine treatment in the month prior to delivery was not sufficient to reduce the odds of postpartum overdose.

PARTICIPANTS

Women who delivered one or more live births from 2012 to 2014 (n = 174 517).

MEASUREMENTS

The primary outcome was opioid-related overdose in the postpartum year. We used multivariable logistic regression to explore the independent associations of maternal (demographics, substance use, pregnancy) and infant [gestational age, birthweight, neonatal abstinence syndrome (NAS)] characteristics with postpartum opioid overdose. Findings were stratified by maternal opioid use disorder (OUD) diagnosis.

FINDINGS

There were 189 deliveries to women who experienced ≥ 1 opioid overdose in the first year postpartum (11 of 10 000 deliveries). Among women with postpartum opioid overdose, 46.6% had an OUD diagnosis within 12 months before delivery. In our adjusted model, maternal diagnosis of OUD [adjusted odds ratio (aOR) = 3.61, 95% confidence interval (CI) = 1.73-7.51] and prior non-fatal overdose (aOR = 2.40, 95% CI = 1.11-5.17) were most strongly associated with postpartum overdose. After stratifying by OUD status, infant diagnosis of NAS (OUD⁺ aOR = 2.03, 95% CI = 1.26-3.27; OUD^- aOR = 2.79, 95% CI = 1.12-6.93) and high unscheduled health-care utilization (OUD⁺ aOR = 2.27, 95% CI = 1.38-3.73; OUD^- aOR = 2.11, 95% CI = 1.24-3.58) were positively associated with postpartum overdose in both groups.

Neurobiology of maternal mental illness

This chapter provides an overview of current research discoveries beginning to uncover the neurobiology of maternal mental illness. Results are described according to standard diagnostic categories (specifically, perinatal depression, perinatal anxiety and OCD, postpartum psychosis and bipolar disorder, and trauma and posttraumatic stress disorder), yet we aim to put this approach in context with the introduction of a classification model for psychiatric research, the research domain criteria, gaining traction in basic and clinical translational fields. We first review a new area of study, the neuroplasticity of the pregnant and postpartum brain, as work here has relevance for understanding the pathophysiology of mental disorders and may provide clues to changes in brain functioning that are related to compromised parenting in the context of postpartum depression. We next provide background information on neuroendocrine and immune changes during pregnancy and, to a lesser extent, the postpartum period, as alterations in these systems are significantly implicated in underlying neurobiology of mental illness for peripartum women. Our discussion of the major mental illnesses for pregnant and postpartum women includes neuroendocrine changes, neuroinflammation, and neurotransmitter alterations, as well as circuit dysfunction. Overall, remarkable progress has been made in identifying variations in neurobiology (and related systems) involved in maternal mental illness; yet, it is clear that, as classified with standard diagnostic systems, these are heterogeneous disorders and there is individual variability in the alterations in neurobiology for the same illness.

Psychological interventions for managing postpartum psychosis: a qualitative analysis of women's and family members' experiences and preferences

BACKGROUND

Postpartum psychosis is a rare, yet severe disorder, in which early identification and immediate intervention are crucial. Despite recommendations for psychological input, little is known about the types of psychological intervention reported to be helpful. The aim of this study was to explore the experiences, needs and preferences for psychological intervention from the perspective of women with postpartum psychosis and from the perspective of family members.

METHODS

Thirteen women and eight family members, including partners were interviewed. The data from these semi-structured interviews were audio-recorded, transcribed and inductively analysed using thematic analysis.

RESULTS

Twelve subthemes were identified and then organised around three main themes: 1) Seeking safety and containment, 2) Recognising and responding to the psychological impact and 3) Planning for the future. These themes highlight the temporal element of recovery from postpartum psychosis, because women's psychological needs and preferences changed over time. Emphasis was initially placed on ensuring safety, followed by a need to connect, process and adjust to their experiences. Additional needs were reported by women and family when planning for the future, including managing the fear of relapse and help to reach a decision about future pregnancies.

CONCLUSION

The results illustrate a range of areas in which psychological intervention could be delivered to facilitate and enhance recovery. Further research is needed to develop meaningful and effective psychological interventions and to investigate the most appropriate timing for this to be offered.

An Analysis of Cellular Communication Network Factor Proteins as Candidate Mediators of Postpartum Psychosis Risk

Postpartum (or puerperal) psychosis (PP) is a severe psychiatric condition associated with hallucinations, delusions, cognitive disorganization, and mood problems, which affects approximately 1-2 out of every 1,000 mothers shortly after childbirth. While the risk factors for, and co-morbidities of, PP are relatively well-defined, currently, the pathophysiology underlying the disorder is very poorly-specified. Here, I argue, on the basis of multiple lines of new evidence, that altered expression of the Cellular Communication Network (CCN) factor proteins (and of the heterodimerizing CCN2 and CCN3 proteins in particular), may be associated with, and possibly causal for, increased PP risk. Future preclinical and clinical studies should aim to test this hypothesis as empirical support for it would provide much-needed clues regarding the biological substrates of PP, and could point to predictive biomarkers for the condition.

Genetic risk scores for major psychiatric disorders and the risk of postpartum psychiatric disorders

Postpartum psychiatric disorders are heritable, but how genetic liability varies by other significant risk factors is unknown. We aimed to (1) estimate associations of genetic risk scores (GRS) for major depression (MD), bipolar disorder (BD), and schizophrenia (SCZ) with postpartum psychiatric disorders, (2) examine differences by prior psychiatric history, and (3) compare genetic and familial risk of postpartum psychiatric disorders. We conducted a nested case-control study based on Danish population-based registers of all women in the iPSYCH2012 cohort who had given birth before December 31, 2015 (n = 8850). Cases were women with a diagnosed psychiatric disorder or a filled psychotropic prescription within one year after delivery (n = 5829 cases, 3021 controls). Association analyses were conducted between GRS calculated from Psychiatric Genomics Consortium discovery meta-analyses for MD, BD, and SCZ and case-control status of a postpartum psychiatric disorder. Parental psychiatric history was associated with postpartum psychiatric disorders among women with previous psychiatric history (OR, 1.14; 95% CI 1.02-1.28) but not without psychiatric history (OR, 1.08; 95% CI: 0.81-1.43). GRS for MD was associated with an increased risk of postpartum psychiatric disorders in both women with (OR, 1.44; 95% CI: 1.19-1.74) and without (OR, 1.88; 95% CI: 1.26-2.81) personal psychiatric history. SCZ GRS was only minimally associated with postpartum disorders and BD GRS was not. Results suggest GRS of lifetime psychiatric illness can be applied to the postpartum period, which may provide clues about distinct environmental or genetic elements of postpartum psychiatric disorders and ultimately help identify vulnerable groups.

Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 1): Randomized Controlled Trial

Background

The frenzy of postbirth events often takes a toll on mothers’ mental well-being, leaving them susceptible to postpartum psychological disorders such as postnatal depression (PND). Social support has been found to be effective in restoring the emotional well-being of new mothers. Therefore, mothers need to be supported during the crucial postpartum period to buffer the negative after effects of childbirth and to promote healthier maternal well-being.

Objective

This study aimed to evaluate the effectiveness of a technology-based peer-support intervention program (PIP) on maternal outcomes during the early postpartum period.

Methods

A randomized, parallel-armed controlled trial was conducted. The study recruited 138 mothers (69 in intervention group, 69 in control group) at risk of PND from a tertiary hospital in Singapore. To support these mothers, 20 peer volunteers were recruited by word of mouth and trained by a psychiatrist in social support skills before the intervention commenced. The 4-week–long intervention included a weekly follow-up with a peer volunteer through phone calls or text messages. The intervention group received peer support in addition to the standard care offered by the hospital. The control group only received postnatal standard care. Maternal outcomes (PND, postnatal anxiety [PNA], loneliness, and perceived social support) were measured with reliable and valid instruments. Data were collected immediately postpartum, at 1 month postpartum and at 3 months postpartum. The general linear model was used to compare the groups for postpartum percentage changes in the outcome variables at first and third months, and the linear mixed model was used to compare the trend over the study period.

Results

There was a statistically significant difference in Edinburgh Postnatal Depression Scale scores (d=–2.11; 95% CI −4.0 to −0.3; P=.03) between the intervention and control groups at 3 months postpartum after adjusting for covariates. The intervention group had a significant change over time compared with the control group.

Conclusions

The technology-based PIP was found to be effective in reducing the risk of PND among new mothers and showed a generally positive trend in reducing PNA and loneliness and increasing perceived social support. This study highlights the importance of training paraprofessionals to provide needed support for new mothers postpartum. A further long-term evaluation of the PIP on maternal and family outcomes and its cost-effectiveness is needed to inform clinical practices.

Trial Registration

ISRCTN Registry ISRCTN14864807; https://www.isrctn.com/ISRCTN14864807

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.9416

Women's experiences of severe postnatal psychiatric illness: a systematic review protocol

BACKGROUND

Super diversity has become a twenty-first-century phenomena in the UK. The Five Year Forward View Plan for Mental Health commits to improving access to Perinatal Mental Health services for all new mothers. Existing research indicates various postnatal mental illness aetiologies, traditional practices and beliefs, which are important to explore during medical consultation to achieve a collaborative relationship between the patient and clinician. The study of severe postnatal psychiatric illnesses is well established in the quantitative literature; however, the subjective experiences of mothers with severe psychiatric illnesses after childbirth have been given little attention. The aim of this systematic review is to synthesise the small body of qualitative findings, which will achieve a deeper understanding of mothers' experiences and understandings. This integration of qualitative data is invaluable in facilitating culturally competent strategies in Western settings and informing future research.

METHODS/DESIGN

This protocol proposes a systematic review of qualitative literature of severe postnatal psychiatric illnesses, using a meta-ethnography approach following the PRISMA-P guidelines. A comprehensive search strategy will be developed to undertake a systematic search via online databases to identify eligible articles. Studies will be considered for eligibility if they include mothers aged 18 and over who have been diagnosed with a severe psychiatric illness during the postnatal period; present primary data on women's illness experiences; use qualitative methods. Titles and abstracts will be screened by the primary reviewer to identify potential papers. Two independent reviewers will access and read texts in full and agree on the final list of included studies. Discrepancies will be resolved via consultation with a third independent reviewer. The final list of included studies for review will be methodologically appraised by two independent reviewers using the Critical Appraisal Skills Programme. This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42018093674.

DISCUSSION

To date, no systematic review following a meta-ethnographic approach on qualitative explorations of mothers worldwide diagnosed with severe postnatal psychiatric illnesses has been conducted. An amalgamation of this information enables a deeper understanding of how severe postnatal psychiatric illnesses manifests across cultures. This information is useful when devising culturally competent care.

SYSTEMATIC REVIEW REGISTRATION

CRD42018093674.

Postpartum psychosis in a non-native language-speaking patient: A perspective on language barriers and cultural competency

Postpartum psychosis is a condition characterised by rapid onset of psychotic symptoms several weeks after childbirth. Outside of its timing and descriptions of psychotic features, minimal research exists due to its relative rarity (1 to 2 per 1000 births in the USA), with greater emphasis on postpartum sadness and depression. With the existing literature, cultural differences and language barriers previously have not been taken into consideration as there are no documented cases of postpartum psychosis in a non–English-speaking patient. Correctly differentiating postpartum psychosis from other postpartum psychiatric disorders requires adeptly evaluating for the presence of psychotic symptoms with in-depth history taking. Here, we present a case of postpartum psychosis in a Japanese-speaking only patient, with an associated clinical course and culturally appropriate approach to treatment. A review of postpartum psychosis and language/cultural considerations are also discussed, with attention on the Japanese concept of ‘Satogaeri bunben’.

Fetal and Infant Outcomes in the Offspring of Parents With Perinatal Mental Disorders: Earliest Influences

Mental illness is highly prevalent and runs in families. Mental disorders are considered to enhance the risk for the development of psychopathology in the offspring. This heightened risk is related to the separate and joint effects of inherited genetic vulnerabilities for psychopathology and environmental influences. The early years of life are suggested to be a key developmental phase in the intergenerational psychopathology transmission. Available evidence supports the idea that early exposure to parental psychopathology, during the pregnancy and first postpartum year, may be related to child psychological functioning beyond the postpartum period, up to adulthood years. This not only highlights the importance of intervening early to break the chain of intergenerational transmission of psychopathology but also raises the question of whether early interventions targeting parental mental disorders in this period may alleviate these prolonged adverse effects in the infant offspring. The current article focuses on the specific risk of psychopathology conveyed from mentally ill parents to the offspring during the pregnancy and first postpartum year. We first present a summary of the available evidence on the associations of parental perinatal mental illness with infant psychological outcomes at the behavioral, biological, and neurophysiological levels. Next, we address the effects of early interventions and discuss whether these may mitigate the early intergenerational transmission of risk for psychopathology. The summarized evidence supports the idea that psychopathology-related changes in parents' behavior and physiology in the perinatal period are related to behavioral, biological, and neurophysiological correlates of infant psychological functioning in this period. These alterations may constitute risk for later development of child and/or adult forms of psychopathology and thus for intergenerational transmission. Targeting psychopathology or mother-infant interactions in isolation in the postnatal period may not be sufficient to improve outcomes, whereas interventions targeting both maternal psychopathology and mother-infant interactions seem promising in alleviating the risk of early transmission.

Maternal bereavement shortly before or during pregnancy and risk of postpartum psychotic illness: a population-based study from Denmark and Sweden

Purpose: Postpartum psychosis is a rare but severe complication following childbirth, with unknown etiology. This study investigated whether the death of a close family member — a source of severe stress — the year before or during pregnancy was associated with an increased risk of psychotic illness in the postpartum period among women without and with a history of psychiatric disorder.

Methods: We studied live births in Denmark during 1978–2008 and births in Sweden during 1973–2006 (n=5,246,978). Information on death of women’s relatives and partners and sociodemographic, health-, and pregnancy-related factors was obtained through linkage with nationwide registries.

Results: The death of a close relative the year before or during pregnancy was not associated with psychotic illness during the first 90 days postpartum among women without (adjusted HR 1.02, 95% CI 0.76–1.37) or with a history of psychiatric disorder (HR 0.96, 95% CI 0.74–1.25). Similarly, there was no association between bereavement and risk of postpartum psychosis according to the timing of the loss (the year before or during pregnancy), the relative’s cause of death (natural or unnatural), or the woman’s relationship to the deceased (parent/sibling or partner/older child).

Conclusions: Death of a close relative, one of the most severe sources of stress, before or during pregnancy was not associated with postpartum psychosis. Therefore, these data do not support the hypothesis that severely stressful life events, such as bereavement around the time of pregnancy, are associated with postpartum psychosis.

Mothers With Postpartum Psychiatric Disorders: Proposal for an Adapted Method to Assess Maternal Sensitivity in Interaction With the Child

About 15% of mothers suffer from postpartum psychiatric disorders, such as depression, anxiety, or psychosis. Numerous studies have shown maternal caregiving behavior to be negatively affected under these circumstances. The current study sets out to shed light on specific caregiving behaviors of affected mothers in the context of parental mental illness at an early stage. There are several methods to assess maternal caregiving behavior in terms of sensitivity. However, all of them have limitations regarding the peculiarities of mothers with postpartum disorders, that is, changes in affect regulation, and the early onset of the disorder postpartum. With the current study, we provide an adapted method to assess maternal sensitivity based on methods recently approved in attachment research. Two groups of mothers, who were either healthy or had different postpartum disorders, were recorded on video during interactions with their infants. Behaviors were rated regarding responsiveness, promptness, appropriateness, intrusiveness, and positive and negative affect. A first analysis revealed an increased number of deficits on all subscales in mothers with postpartum psychiatric disorders as compared to healthy mothers. Depressive mothers with a single diagnosis had lower scores in responsiveness, promptness, and appropriateness and higher scores on intrusiveness as compared to those in healthy mothers. Here, maternal behavior appears more parent-centered, whereas affect seemed to be relatively unharmed. Moreover, as compared to healthy mothers, mothers with comorbid depression and anxiety symptomatology achieved lower scores on responsiveness, appropriateness, and positive affect and higher scores on intrusiveness and negative affect. It is suggested, that increased deficits are related to the severity of illness in mothers with comorbidities. Results on promptness indicate that these mothers are still capable of maintaining higher vigilance to infant cues. Variance in maternal behavior was relatively high in clinical mothers, showing that some of them are well capable of behaving in a sensitive manner toward their child. One strength of our adapted method is that particular aspects of sensitive parent-child interactions are assessed separately. This may shed light on specific behavior patterns of different postpartum psychiatric disorders, which may in turn relate to specific child outcomes. The manual is open for usage, while reliability testing is required.

Brain plasticity in pregnancy and the postpartum period: links to maternal caregiving and mental health

Pregnancy and the postpartum period involve numerous physiological adaptations that enable the development and survival of the offspring. A distinct neural plasticity characterizes the female brain during this period, and dynamic structural and functional changes take place that accompany fundamental behavioral adaptations, stimulating the female to progress from an individual with self-directed needs to being responsible for the care of another life. While many animal studies detail these modifications, an emerging body of research reveals the existence of reproduction-related brain plasticity in human mothers too. Additionally, associations with aspects of maternal caregiving point to adaptive changes that benefit a woman's transition to motherhood. However, the dynamic changes that affect a woman's brain are not merely adaptive, and they likely confer a vulnerability for the development of mental disorders. Here, we review the changes in brain structure and function that a woman undergoes during the peripartum period, outlining associations between these neural alterations and different aspects of maternal care. We additionally discuss peripartum mood disorders and postpartum psychosis, and review the neuroimaging studies that investigate the neural bases of these conditions.

The psychometric properties of the 16-item version of the Prodromal Questionnaire (PQ-16) as a screening instrument for perinatal psychosis

Psychiatric illness can pose serious risks to pregnant and postpartum women and their infants. There is a need for screening tools that can identify women at risk for postpartum psychosis, the most dangerous perinatal psychiatric illness. This study used exploratory factor analysis (EFA) and Rasch item response theory (IRT) models to evaluate the psychometric properties and construct validity of the Spanish language version of the 16-item Prodromal Questionnaire (PQ-16) as a screening tool for psychosis in a population of pregnant Peruvian women. The EFA yielded a four-factor model, which accounted for 44% of the variance. Factor 1, representing "unstable sense of self," accounted for 22.1% of the total variance; factor 2, representing "ideas of reference/paranoia," for 8.4%; factor 3, representing "sensitivity to sensory experiences," accounted for 7.2%; and factor 4, possibly representing negative symptoms, accounted for 6.3%. Rasch IRT analysis found that all of the items fit the model. These findings support the construct validity of the PQ-16 in this pregnant Peruvian population. Also, further research is needed to establish definitive psychiatric diagnoses to determine the predictive power of the PQ-16 as a screening tool.

SULFATION PATHWAYS: The steroid sulfate axis and its relationship to maternal behaviour and mental health

Steroid hormones can exist in functionally dissociable sulfated and non-sulfated (free) forms and can exert profound effects on numerous aspects of mammalian physiology; the ratio of free-to-sulfated steroids is governed by the antagonistic actions of steroid sulfatase (STS) and sulfotransferase (SULT) enzymes. Here, I examine evidence from human and animal model studies, which suggests that STS and its major substrate (dehydroepiandrosterone sulfate, DHEAS) and product (DHEA) can influence brain function, behaviour and mental health, before summarising how the activity of this axis varies throughout mammalian pregnancy and the postpartum period. I then consider how the steroid sulfate axis might impact upon normal maternal behaviour and how its dysfunction might contribute towards risk of postpartum psychiatric illness. Understanding the biological substrates underlying normal and abnormal maternal behaviour will be important for maximising the wellbeing of new mothers and their offspring.

Improvement of postpartum depression and psychosis after electroconvulsive therapy: A population-based study with a matched comparison group

INTRODUCTION

Electroconvulsive therapy (ECT) is used to treat postpartum depression and psychosis based on clinical experience and small observational studies.

AIMS

The primary aim was to test the hypothesis that the response rate to ECT for depression and psychosis is higher during the postpartum period than outside this period. The secondary aim was to identify predictors of a response to ECT during the postpartum period.

MATERIALS AND METHODS

Cases with postpartum depression and/or psychosis received ECT within 6 months of delivery. A matched comparison group with depression and/or psychosis (not within the postpartum period) was identified from the Swedish National Quality Register for ECT. The improvement 1 week after ECT was classified according to the Clinical Global Impressions Scale - Improvement scale (CGI-I) as responder (CGI-I score 1-2) or non-responder (CGI-I score 3-7).

RESULTS

185 cases and 185 comparison group subjects were included (46% with psychosis in each groups). More cases (87.0%) than comparison group subjects (73.5%) responded to ECT (p = 0.001). Adjusted binary regression analysis revealed that more severe symptoms prior to treatment were the only statistically significant predictor of response.

LIMITATIONS

There was no control group without ECT treatment.

CONCLUSION

The response rate of those with postpartum depression and/or psychosis to ECT was high. The response rate of patients with psychosis or depression was higher during the postpartum period than outside it. This study supports the use of ECT for severe forms of postpartum depression and/or psychosis.

One-Year Follow-Up of Women with Severe Acute Maternal Morbidity (SAMM): A Cohort Study

Background

Some women experience unforeseen complications during pregnancy and childbirth, which may be life threatening; their survival depends on intensive support and timely interventions. The aim of this study was to assess the long-term prevalence of adverse health conditions and their impact on quality of life in women who had severe acute maternal morbidity (SAMM).

Methods

This is a prospective cohort study comprising 43 women with SAMM during 2015 (exposure group) and 43 women who had an uneventful pregnancy and delivery (non-exposure group) during the same study period. Those who consented were given an additional follow-up date for free medical health check at 1 year.

Results

The incidence of SAMM during study period was 8.6/1000 births. There were five deaths in the exposure group. Adverse health events were seen in 30 (78.94%) out of 38 survivors. Abnormal lipid profile, thrombocytopenia, cardiac diastolic dysfunction, amenorrhoea, Sheehan and Asherman syndrome were major findings in the exposed group. Four (10.52%) women required re-admission, and eight (20.05%) required additional procedures to confirm screening abnormalities. The exposure group had higher mean scores on the EPDS scale, incidence of suicidal thoughts and poorer performance in the WHOQOL BREF psychological domain.

Conclusion

Health programmes need to focus on maternal health, provide medical treatment and psychological support for a longer duration than the traditional 6 weeks postpartum in women who experience SAMM.

Mothers with acute and chronic postpartum psychoses and impact on the mother-infant interaction

BACKGROUND

Maternal postpartum psychoses pose a serious risk to the mother-infant interaction. It is unclear how different subtypes of postpartum psychosis, including acute and chronic, might differentially affect the mother-infant interaction.

METHOD

A systematic search of electronic journal databases was performed.

RESULTS

This systematic review yielded 17 studies with adequate overall study quality. They focused on child custody and involvement of social services as indirect indicators of the mother-infant interaction, observed mother-infant interactions as direct indicators, or potential transitional mechanisms, including memory processing, mind-mindedness, and affect recognition, that may partially explain the effects of psychotic disorders. An acute onset of psychosis during the postpartum period (de novo or relapse) was typically related to better mother-infant interactions. Mothers with schizophrenia have the highest risk of child displacement, and interventions by social services were more likely. However, mothers with postpartum schizophrenia did not exhibit more harm to the child or self-harm than mothers with postpartum depression. Heterogeneity of methodology, case definitions, and assessments characterized the studies; hence, they were not pooled.

CONCLUSIONS

In addition to evaluating social risk factors in patients with acute onset and chronic psychoses during the postpartum period, negative preconceptions about motherhood and schizophrenia have to be carefully examined. Clinical research on postpartum psychoses should consider the onset criteria, prevalence of self-harm or harm to the child, significance of specific (e.g., religious) delusions and expressed hostility toward the child. More studies on the impact of first-onset (de novo) postpartum psychoses on the mother-infant interaction are needed.

Birth experiences, trauma responses and self-concept in postpartum psychotic-like experiences

The frequency of psychotic-like experiences (PLEs) amongst new mothers is beginning to be explored but the mechanisms underlying such experiences are yet to be understood. First time mothers (N=10,000) receiving maternity care via the UK National Health Service were contacted postnatally via Emma's Diary, an online resource for mothers. Measures assessed birth experience, trauma appraisals, post-traumatic stress symptoms, adjustment to motherhood, self-concept clarity and PLEs (in the form of hallucinations and delusions). There was a 13.9% response rate (N=1393) and 1303 participants reported experiencing at least one PLE (93.5%). Three competing nested path models were analysed. A more negative birth experience directly predicted delusions, but not hallucinations. Trauma appraisals and poorer adjustment to motherhood indirectly predicted PLEs, via disturbed self-concept clarity. Post-traumatic stress symptoms directly predicted the occurrence of all PLEs. PLEs in first time mothers may be more common than previously thought. A key new understanding is that where new mothers have experienced birth as traumatic and are struggling with adjustment to their new role, this can link to disturbances in a coherent sense of self (self-concept clarity) and be an important predictor of PLEs. Understanding the development of PLEs in new mothers may be helpful in postnatal care, as would public health interventions aimed at reducing the sense of abnormality or stigma surrounding such experiences.

Evaluation of Technology-Based Peer Support Intervention Program for Preventing Postnatal Depression: Protocol for a Randomized Controlled Trial

BACKGROUND

Multiple international agencies, including the World Health Organization and the International Monetary Fund, have emphasized the importance of maternal mental health for optimal child health and development. Adequate social support is vital for the most vulnerable to postpartum mood disorders. Hence, an urgent need for sustainable social support programs to aid mothers ease into their new parenting role exists.

OBJECTIVE

This study protocol aims to examine the effectiveness of a technology-based peer support intervention program among mothers at risk for postnatal depression in the early postpartum period.

METHODS

A randomized controlled 2-group pretest and repeated posttest experimental design will be used. The study will recruit 118 mothers from the postnatal wards of a tertiary public hospital in Singapore. Eligible mothers will be randomly allocated to receive either the peer support intervention program or routine perinatal care from the hospital. Peer volunteers will be mothers who have experienced self-reported depression and will be receiving face-to-face training to support new mothers at risk of depression. Outcome measures include postnatal depression, anxiety, loneliness, and social support. Data will be collected at immediate postnatal period (day of discharge from the hospital), at fourth week and twelfth week post childbirth.

RESULTS

The recruitment and training of peer support volunteers (N=20) ended in June 2017, whereas recruitment of study participants commenced in July 2017 and is still ongoing. The current recruitment for new mothers stands at 73, with 36 in the control group and 37 in the intervention group. Data collection is projected to be completed by May 2018.

CONCLUSIONS

This study will identify a potentially effective and clinically useful method to prevent postnatal depression in new mothers, which is the top cause of maternal morbidity. Receiving social support from others who share similar experiences may enhance the positive parenting experiences of mothers, which in turn can improve the psychosocial well-being of the mothers, tighten mother-child bond, and enhance overall family dynamics for mothers and infants.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number ISRCTN14864807; http://www.isrctn.com/ISRCTN14864807 (Archived by WebCite at http://www.webcitation.org/6xtBNvBTX).

Postpartum depression in India: a systematic review and meta-analysis

OBJECTIVE

To provide an estimate of the burden of postpartum depression in Indian mothers and investigate some risk factors for the condition.

METHODS

We searched PubMed®, Google Scholar and Embase® databases for articles published from year 2000 up to 31 March 2016 on the prevalence of postpartum depression in Indian mothers. The search used subject headings and keywords with no language restrictions. Quality was assessed via the Newcastle-Ottawa quality assessment scale. We performed the meta-analysis using a random effects model. Subgroup analysis and meta-regression was done for heterogeneity and the Egger test was used to assess publication bias.

FINDINGS

Thirty-eight studies involving 20 043 women were analysed. Studies had a high degree of heterogeneity (I2  = 96.8%) and there was evidence of publication bias (Egger bias = 2.58; 95% confidence interval, CI: 0.83-4.33). The overall pooled estimate of the prevalence of postpartum depression was 22% (95% CI: 19-25). The pooled prevalence was 19% (95% CI: 17-22) when excluding 8 studies reporting postpartum depression within 2 weeks of delivery. Small, but non-significant differences in pooled prevalence were found by mother's age, geographical location and study setting. Reported risk factors for postpartum depression included financial difficulties, presence of domestic violence, past history of psychiatric illness in mother, marital conflict, lack of support from husband and birth of a female baby.

CONCLUSION

The review shows a high prevalence of postpartum depression in Indian mothers. More resources need to be allocated for capacity-building in maternal mental health care in India.