Postpartum psychiatric disorders

The Indirect Effect of Parental Intolerance of Uncertainty on Perinatal Mental Health via Mindfulness During COVID-19

Objectives

The COVID-19 pandemic is associated with mental health difficulties, especially during pregnancy and early postpartum. Intolerance of uncertainty (IU) and reduced capacity for mindfulness-a protective factor for child-bearers-may be particularly relevant factors driving mental health problems given the unpredictable nature of the pandemic. The current study aims to shed light on modifiable paths to perinatal psychological distress by testing whether there is an indirect effect of IU on psychological symptoms through a perceived reduction in mindfulness during the pandemic.

Methods

Pregnant individuals (67%, n = 133) and new mothers within 6 months postpartum (33%, n = 66) participated in a cross-sectional online survey assessing IU, current and retrospective pre-pandemic mindfulness (FFMQ), and psychological symptoms (anxiety, depression, somatization; BSI). Perceived change in mindfulness was captured by including retrospective mindfulness as a covariate in the PROCESS macro used for analyses.

Results

Tests of the direct association between mindfulness, IU, and psychological symptoms showed significant effects of IU (b = 0.46, SE = 0.064; p < .001) and perceived decrease in mindfulness during the pandemic (b =  - 0.72, SE = 0.08, p < .001) on psychological symptoms (R ² = .21-.34; F[2, 197] = 51.13-52.81, p < .001). The indirect effect of IU on symptoms via perceived decrease in mindfulness during the pandemic (b = 0.13, SE = 0.043, 95%CI [.060, .226]) was significant (R ² = .41, F[3, 195] = 45.08, p < .001).

Conclusions

Results suggest that mothers who are less able to tolerate uncertainty experience more psychological symptoms, in part due to perceived reduction in mindfulness during the pandemic. Future research should examine whether IU is a screening risk marker and target for mindfulness-based interventions to improve maternal well-being and family outcomes.

Heart rate variability in late pregnancy: exploration of distinctive patterns in relation to maternal mental health

Exploration of photoplethysmography (PPG), a technique that can be translated to the clinic, has the potential to assess the autonomic nervous system (ANS) through heart rate variable (HRV) in pregnant individuals. This novel study explores the complexity of mental health of individuals in a clinical sample responding to a task in late pregnancy; finding those with several types of past or current anxiety disorders, greater trait anxiety, or greater exposure to childhood traumatic events had significantly different HRV findings from the others in the cohort. Lower high frequency (HF), a measure of parasympathetic activity, was found for women who met the criteria for the history of obsessive-compulsive disorder (OCD) (p = 0.004) compared with women who did not meet the criteria for OCD, and for women exposed to greater than five childhood traumatic events (p = 0.006) compared with those exposed to four or less childhood traumatic events. Conversely higher low frequency (LF), a measure thought to be impacted by sympathetic system effects, and the LF/HF ratio was found for those meeting criteria for a panic disorder (p = 0.006), meeting criteria for social phobia (p = 0.002), had elevated trait anxiety (p = 0.006), or exposure to greater than five childhood traumatic events (p = 0.004). This study indicates further research is needed to understand the role of PPG and in assessing ANS functioning in late pregnancy. Study of the impact of lower parasympathetic functioning and higher sympathetic functioning separately and in conjunction at baseline and in relation to tasks during late pregnancy has the potential to identify individuals that require more support and direct intervention.

Postpartum psychiatric disorders and subsequent live birth: a population-based cohort study in Denmark

STUDY QUESTION

Are women with a history of first-onset postpartum psychiatric disorders after their first liveborn delivery less likely to have a subsequent live birth?

SUMMARY ANSWER

Women with incident postpartum psychiatric disorders are less likely to go on to have further children.

WHAT IS KNOWN ALREADY

Women are particularly vulnerable to psychiatric disorders in the postpartum period. The potential effects of postpartum psychiatric disorders on the mother's future chances of live birth are so far under-researched.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study consisted of 414 571 women who had their first live birth during 1997-2015. We followed the women for a maximum of 19.5 years from the date of the first liveborn delivery until the next conception leading to a live birth, emigration, death, their 45th birthday or 30 June 2016, whichever occurred first.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Postpartum psychiatric disorders were defined as filling a prescription for psychotropic medications or hospital contact for psychiatric disorders for the first time within 6 months postpartum. The outcome of interest was time to the next conception leading to live birth after the first liveborn delivery. Records on the death of a child were obtained through the Danish Register of Causes of Death. Cox regression was used to estimate the hazard ratios (HRs), stratified by the survival status of the first child.

MAIN RESULTS AND THE ROLE OF CHANCE

Altogether, 4327 (1.0%) women experienced postpartum psychiatric disorders after their first liveborn delivery. The probability of having a subsequent live birth was 69.1% (95% CI: 67.4-70.7%) among women with, and 82.3% (95% CI: 82.1-82.4%) among those without, postpartum psychiatric disorders. Women with postpartum psychiatric disorders had a 33% reduction in the rate of having second live birth (HR = 0.67, 95% CI: 0.64-0.69), compared to women without postpartum psychiatric disorders. The association disappeared if the first child died (HR = 1.01, 95% CI: 0.85-1.20). If postpartum psychiatric disorders required hospitalisations, this was associated with a more pronounced reduction in live birth rate, irrespective of the survival status of the first child (HR = 0.54, 95% CI: 0.47-0.61 if the first child survived, and HR = 0.49, 95% CI: 0.23-1.04 if the first child died).

LIMITATIONS, REASONS FOR CAUTION

The use of population-based registers allows for the inclusion of a representative cohort with almost complete follow-up. The large sample size enables us to perform detailed analyses, accounting for the survival status of the child. However, we did not have accurate information on stillbirths and miscarriages, and only pregnancies that led to live birth were included.

WIDE IMPLICATIONS OF THE FINDINGS

Our study is the first study to investigate subsequent live birth after postpartum psychiatric disorders in a large representative population. The current study indicates that postpartum psychiatric disorders have a significant impact on subsequent live birth, as women experiencing these disorders have a decreased likelihood of having more children. However, the variations in subsequent live birth rate are influenced by both the severity of the disorders and the survival status of the first-born child, indicating that both personal choices and decreased fertility may have a role in the reduced subsequent live birth rate among women with postpartum psychiatric disorders.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Danish Council for Independent Research (DFF-5053-00156B), the European Union's Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No. 837180, AUFF NOVA (AUFF-E 2016-9-25), iPSYCH, the Lundbeck Foundation Initiative for Integrative Psychiatric Research (R155-2014-1724), Niels Bohr Professorship Grant from the Danish National Research Foundation and the Stanley Medical Research Institute, the National Institute of Mental Health (NIMH) (R01MH104468) and Fabrikant Vilhelm Pedersen og Hustrus Legat. The authors do not declare any conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Clinical characteristics of bipolar disorders with postpartum depressive onset

BACKGROUND

Postpartum period is associated with an increased risk of bipolar disorder diagnosis and relapse, mainly major depressive episode. Onset during this period might be associated with specific characteristics.

AIM

To compare the socio-demographic and clinical characteristics of parous women presenting with bipolar disorder and an index depressive episode occurring during or outside the postpartum period.

METHODS

Using the multicenter cohort FACE-BD (FondaMental Academic Centers of Expertise for Bipolar Disorders), we considered all women who started their BD with a major depressive episode and have at least one child. We compared two groups depending on the onset: in or outside the postpartum period.

RESULTS

Among the 759 women who started BD with a major depressive episode, 93 (12.2%) had a postpartum onset, and 666 (87.8%) had not. Women who started BD in the postpartum period with a major depressive episode have a more stable family life, more children, an older age at onset, more Bipolar 2 disorder, less history of suicide attempts, less depressive episodes and more mood stabilizer treatments as compared to those who started with a major depressive episode outside the postpartum period. The multivariable logistic regression showed that women with an onset in the postpartum period had significantly more children, less lifetime depressive episodes and a lower rate of history of suicide attempts as compared to women with an onset outside the postpartum period.

DISCUSSION

Our results suggest that women starting their BD with postpartum depression have a more favorable course of BD, especially less history of suicide attempt and less lifetime depressive episodes.

Factors Affecting Infant Feeding Practices Among Women With Severe Mental Illness

Background: The health benefits of breastfeeding are well-established but for mothers with severe mental illness (SMI), the decision to breastfeed can be complex. Very few prior studies have investigated the infant feeding choices of women with SMI, or the factors associated with this. Our aims were to examine antenatal infant feeding intentions and infant feeding outcomes in a cohort of women admitted for acute psychiatric care in the first postpartum year. We also aimed to examine whether demographic and clinical characteristics associated with breastfeeding were similar to those found in previous studies in the general population, including age, employment, education, BMI, mode of delivery, smoking status, and social support. Methods: This study was a mixed-methods secondary analysis of a national cohort study, ESMI-MBU (Examining the effectiveness and cost-effectiveness of perinatal mental health services). Participants had been admitted to acute care with SMI in the first postpartum year. Infant feeding outcomes were retrospectively self-reported by women during a 1-month post-discharge interview. Free-text responses to questions relating to infant feeding and experience of psychiatric services were also explored using thematic analysis. Results: 144 (66.1%) of 218 women reported breastfeeding (mix feeding and exclusive breastfeeding). Eighty five percentage of the cohort had intended to breastfeed and of these, 76.5% did so. Factors associated with breastfeeding included infant feeding intentions, employment and non-Caucasian ethnicity. Although very few women were taking psychotropic medication contraindicated for breastfeeding, over a quarter (n = 57, 26.15%) reported being advised against breastfeeding because of their medication. Women were given this advice by psychiatry practitioners (40% n = 22), maternity practitioners (32.73% n = 18) and postnatal primary care (27.27% n = 15). Most women stopped breastfeeding earlier than they had planned to as a result (81.1% n = 43). Twenty five women provided free text responses, most felt unsupported with infant feeding due to inconsistent information about medication when breastfeeding and that breastfeeding intentions were de-prioritized for mental health care. Conclusion: Women with SMI intend to breastfeed and for the majority, this intention is fulfilled. Contradictory and insufficient advice relating to breastfeeding and psychotropic medication indicates that further training is required for professionals caring for women at risk of perinatal SMI about how to manage infant feeding in this population. Further research is required to develop a more in-depth understanding of the unique infant feeding support needs of women with perinatal SMI.

Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven.

METHODS

This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms.

DISCUSSION

The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153864 . Registered on November 6, 2019.

Brexanolone in Postpartum Depression: Post Hoc Analyses to Help Inform Clinical Decision-Making

Background: Brexanolone (BRX) injection was approved by the United States Food and Drug Administration in 2019 for the treatment of adults with postpartum depression (PPD) based on two Phase 3 clinical trials. Materials and Methods: Data from the three trials were combined. PPD-specific 17-item Hamilton Rating Scale for Depression (HAMD-17) group-level minimal important difference (MID) and patient-level meaningful change (meaningful change threshold [MCT]) were estimated and applied to differences in BRX versus placebo (PBO) at hour 60 (primary endpoint) and day 30 (end of trial follow-up). Likelihood of HAMD-17 response and remission and Clinical Global Impression of Improvement (CGI-I) response for BRX versus PBO were assessed at hour 60 and as sustained through day 30 using relative risk. Associated number needed to treat (NNT) and number needed to harm (NNH) values were also estimated. Results: Two-hundred nine patients were included. The average HAMD-17 MID estimate was -2.1; the least-squared mean difference between BRX and PBO exceeded this at hour 60 and day 30. Minimal, moderate, and large MCTs were estimated to be -9, -15, and -20 points, respectively. Significantly more BRX-treated than PBO-treated patients achieved minimal, moderate, and large change (all ps < 0.05) at hour 60 and large meaningful response at day 30 (p < 0.05). BRX-treated patients were more likely to sustain HAMD-17 remission and CGI-I response through day 30 versus PBO. NNTs ranged from 4 to 8, with NNH of 97. Conclusions: BRX provided meaningful changes relative to PBO, rapid (hour 60), and sustained improvements (day 30) in PPD symptoms, low NNT, and large NNH. These results may help inform treatment decision-making. Clinicaltrials.gov registration numbers: NCT02614547, NCT02942004, and NCT02942017.

Disordered eating in the postpartum period: Role of psychological distress, body dissatisfaction, dysfunctional maternal beliefs and self-compassion

The present cross-sectional study tested the affect regulation model of disordered eating for women in the postpartum period, whereby disordered eating is used to cope with psychological distress. Two hundred and two women who had given birth in the last two years completed an online survey of self-report measures of study variables. Path analyses supported the primary hypothesis: negative affect mediated relationships between body dissatisfaction, dysfunctional maternal beliefs, negative components of self-compassion and disordered eating behaviours, particularly binge eating. Results suggest that negative affect plays a central role in postpartum disordered eating. Interventions to address maladaptive emotion regulation strategies, specifically targeting body image distress and self-critical maternal thoughts may improve eating behaviours for this population.

Development and validation of a machine learning algorithm for predicting the risk of postpartum depression among pregnant women

OBJECTIVE

There is a scarcity in tools to predict postpartum depression (PPD). We propose a machine learning framework for PPD risk prediction using data extracted from electronic health records (EHRs).

METHODS

Two EHR datasets containing data on 15,197 women from 2015 to 2018 at a single site, and 53,972 women from 2004 to 2017 at multiple sites were used as development and validation sets, respectively, to construct the PPD risk prediction model. The primary outcome was a diagnosis of PPD within 1 year following childbirth. A framework of data extraction, processing, and machine learning was implemented to select a minimal list of features from the EHR datasets to ensure model performance and to enable future point-of-care risk prediction.

RESULTS

The best-performing model uses from clinical features related to mental health history, medical comorbidity, obstetric complications, medication prescription orders, and patient demographic characteristics. The model performances as measured by area under the receiver operating characteristic curve (AUC) are 0.937 (95% CI 0.912 - 0.962) and 0.886 (95% CI 0.879-0.893) in the development and validation datasets, respectively. The model performances were consistent when tested using data ending at multiple time periods during pregnancy and at childbirth.

LIMITATIONS

The prevalence of PPD in the study data represented a treatment prevalence and is likely lower than the illness prevalence.

CONCLUSIONS

EHRs and machine learning offer the ability to identify women at risk for PPD early in their pregnancy. This may facilitate scalable and timely prevention and intervention, reducing negative outcomes and the associated burden.

Social Behavior as a Transdiagnostic Marker of Resilience

The recent shift from psychopathology to resilience and from diagnosis to functioning requires the construction of transdiagnostic markers of adaptation. This review describes a model of resilience that is based on the neurobiology of affiliation and the initial condition of mammals that mature in the context of the mother's body and social behavior. The model proposes three tenets of resilience-plasticity, sociality, and meaning-and argues that coordinated social behavior stands at the core sustaining resilience. Two lines in the maturation of coordinated social behavior are charted, across animal evolution and throughout human development, culminating in the mature human reciprocity of empathy, mutuality, and perspective-taking. Cumulative evidence across ages and clinical conditions and based on our behavioral coding system demonstrates that social reciprocity, defined by plasticity at the individual, dyadic, and group levels, denotes resilience, whereas the two poles of disengagement/avoidance and intrusion/rigidity characterize specific psychopathologies, each with a distinct behavioral signature. Attention to developmentally sensitive markers and to the dimension of meaning in human sociality may open new, behavior-based pathways to resilience.

Metabolic Profiling Indicates Diversity in the Metabolic Physiologies Associated With Maternal Postpartum Depressive Symptoms

Background: Postpartum depression (PPD) is a devastating disease requiring improvements in diagnosis and prevention. Blood metabolomics identifies biological markers discriminatory between women with and those without antenatal depressive symptoms. Whether this cutting-edge method can be applied to postpartum depressive symptoms merits further investigation. Methods: As a substudy within the Biology, Affect, Stress, Imagine and Cognition Study, 24 women with PPD symptom (PPDS) assessment at 6 weeks postpartum were included. Controls were selected as having a score of ≤ 6 and PPDS cases as ≥12 on the Edinburgh Postnatal Depression Scale. Blood plasma was collected at 10 weeks postpartum and analyzed with gas chromatography-mass spectrometry metabolomics. Results: Variations of metabolomic profiles within the PPDS samples were identified. One cluster showed altered kidney function, whereas the other, a metabolic syndrome profile, both previously associated with depression. Five metabolites (glycerol, threonine, 2-hydroxybutanoic acid, erythritol, and phenylalanine) showed higher abundance among women with PPDSs, indicating perturbations in the serine/threonine and glycerol lipid metabolism, suggesting oxidative stress conditions. Conclusions: Alterations in certain metabolites were associated with depressive pathophysiology postpartum, whereas diversity in PPDS physiologies was revealed. Hence, plasma metabolic profiling could be considered in diagnosis and pathophysiological investigation of PPD toward providing clues for treatment. Future studies require standardization of various subgroups with respect to symptom onset, lifestyle, and comorbidities.

A Primer on DNA Methylation and Its Potential to Impact Maternal Depression Risk and Assessment During Pregnancy and the Postpartum

Depression onset during and after pregnancy is prevalent and associated with significant implications for maternal, child, and family health. Although environmental risk factors important to the expression of pregnancy-related depression are well known, knowledge of the genetic underpinning is limited. Given the joint contribution of environmental and genetic factors to depression risk liability, DNA methylation presents itself as an ideal biomarker to investigate basic mechanisms and opportunities for translational research to care for pregnancy-related depression health outcomes. This article is an introduction to DNA methylation and its potential to serve as a marker of depression risk during pregnancy and the postpartum. This commentary discusses current clinical uses of DNA methylation-based testing and how it may be applied to perinatal depression clinical care and management.

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.

Postpartum Depression: Current Status and Possible Identification Using Biomarkers

Postpartum depression (PPD) is a serious health issue that can affect about 15% of the female population within after giving birth. It often conveys significant negative consequences to the offsprings. The symptoms and risk factors are somewhat similar to those found in non-postpartum depression. The main difference resides in the fact that PPD is triggered by postpartum specific factors, including especially biological changes in the hormone levels. Patients are usually diagnosed using a questionnaire onsite or in a clinic. Treatment of PPD often involves psychotherapy and antidepressant medications. In recent years, there have been more researches on the identification of biological markers for PPD. In this review, we will focus on the current research status of PPD, with an emphasis on the recent progress made on the identification of PPD biomarkers.

Neurobiology of peripartum mental illness

At least one in seven pregnant or recently postpartum women will experience a mental illness such as an anxiety disorder, depressive disorder, or substance use disorder. These mental illnesses have detrimental effects on the health of the mother, child, and family, but little is known about the hypothalamic and other neural correlates of maternal mental health concerns. The transition to parenthood alone is a time of remarkable neural plasticity, so it is perhaps not surprising that current research is showing that maternal mental illness has unique neural profiles. Furthermore, the neural systems affected by peripartum mental illness overlap and interact with the systems involved in maternal caregiving behaviors, and mother-infant interactions are, therefore, highly susceptible to disruption. This review discusses what we know about the unique neural changes occurring during peripartum mental illness and the role of the hypothalamus in these illnesses. With an improved understanding of the neural correlates of maternal mental health and disease, we will be better equipped to predict risk, develop effective treatments, and ultimately prevent suffering for millions of parents during this critical time in life.

Effectiveness of Probiotic, Prebiotic, and Synbiotic Supplementation to Improve Perinatal Mental Health in Mothers: A Systematic Review and Meta-Analysis

Introduction: There is an emerging interest in modulating the gut microbiota to target the gut-brain axis and improve maternal mental health in the perinatal period. This systematic review evaluated the effectiveness of prebiotics, probiotics, and synbiotics supplementation during pregnancy to reduce the risk of maternal mental health problems in the perinatal period. Methods: Electronic biomedical databases and clinical trial registries were searched from database inception through August 2020 to identify randomized controlled clinical trials (RCTs) evaluating the effect of probiotic, prebiotic, or synbiotic supplements administered to women during pregnancy on measures of perinatal depression, anxiety, and other mental health outcomes. Study selection, risk of bias appraisal, and data extraction were independently performed by two reviewers. Pooled mean differences (MD) and odds ratios (pOR) with 95% confidence intervals (CI) were calculated in random-effects meta-analyses for the outcomes of interest in the review. Results: From 3,868 studies identified through the search strategy, three RCTs of low risk of bias involving 713 participants were included, all three testing probiotics. There were no differences between probiotics and control groups in the mean depression scores (MD -0.46; 95% CI -2.16, 1.25) at end of follow-up. Although statistical significance was not achieved, probiotics showed an advantage in the proportion of participants scoring below an established cut-off for depression (pOR 0.68; 95% CI 0.43, 1.07). Compared to placebo, probiotics in pregnancy reduced anxiety symptoms (MD -0.99; 95% CI -1.80, -0.18); however, this advantage was not translated in a reduction in the proportion of participants scoring above an established cut-off for anxiety (pOR 0.65; 95% CI 0.23, 1.85). There were no differences between probiotics and control groups in global mental health scores at end of follow-up (MD 1.09; 95% CI -2.04, 4.22). Conclusion: There is limited but promising evidence about the effectiveness of probiotics during pregnancy to reduce anxiety symptoms and reduce the proportion of women scoring ABOVE a cut-off depression score. There is a lack of RCT evidence supporting prebiotics and synbiotics supplementation for similar purposes in the perinatal period. More research is needed before prebiotics, probiotics, and synbiotics are recommended to support maternal mental health and well-being in the perinatal period. Systematic Review Registration: PROSPERO, CRD42019137158.

Indirect psychiatric consultation for perinatal bipolar disorder: A scoping review

OBJECTIVE

To synthesize the literature and develop guidance on supports needed for primary care and perinatal providers in screening, initial management, triage, and bridging treatment for perinatal bipolar disorder.

METHODS

We conducted a scoping review by searching six electronic databases using keywords related to perinatal bipolar disorder. We summarized descriptive statistics on settings and extracted information on care approaches. We synthesized the literature on indirect care models and extracted data on screening, follow-up, referrals, and management.

RESULTS

1169 articles were retrieved. 51 articles were included after review. Most papers were reviews. Fewer addressed care in obstetric (n = 20, 39%), primary care (n = 10, 20%), and pediatric settings (n = 2, 4%). Most papers (n = 30, 59%) discussed using screening instruments for bipolar disorder. Articles were mixed on recommendations for bipolar disorder screening.

CONCLUSIONS

Varied strategies for structured assessment exist and are influenced by practice setting. There remains uncertainty about optimal strategies for screening and management of perinatal bipolar disorder. We recommend screening for bipolar disorder in the perinatal period in select circumstances (with depression screening, known bipolar disorder risk factors, and prior to starting antidepressants). If specialty mental health care is unavailable, we recommend enhancing usual care through integrated care strategies such as indirect consultation.

Endogenous antagonists of N-methyl-d-aspartate receptor in schizophrenia

Schizophrenia is a chronic neuropsychiatric brain disorder that has devastating personal impact and rising healthcare costs. Dysregulation of glutamatergic neurotransmission has been implicated in the pathobiology of the disease, attributed largely to the hypofunction of the N-methyl-d-aspartate (NMDA) receptor. Currently, there is a major gap in mechanistic analysis as to how endogenous modulators of the NMDA receptors contribute to the onset and progression of the disease. We present a systematic review of the neurobiology and the role of endogenous NMDA receptor antagonists in animal models of schizophrenia, and in patients. We discuss their neurochemical origin, release from neurons and glia with action mechanisms, and functional effects, which might contribute toward the impairment of neuronal processes underlying this complex pathological state. We consider clinical evidence suggesting dysregulations of endogenous NMDA receptor in schizophrenia, and highlight the pressing need in future studies and emerging directions, to restore the NMDA receptor functions for therapeutic benefits.

Beyond the Mind-Serum Trace Element Levels in Schizophrenic Patients: A Systematic Review

The alterations in serum trace element levels are common phenomena observed in patients with different psychiatric conditions such as schizophrenia, autism spectrum disorder, or major depressive disorder. The fluctuations in the trace element concentrations might act as potential diagnostic and prognostic biomarkers of many psychiatric and neurological disorders. This paper aimed to assess the alterations in serum trace element concentrations in patients with a diagnosed schizophrenia. The authors made a systematic review, extracting papers from the PubMed, Web of Science, and Scopus databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Among 5009 articles identified through database searching, 59 of them were assessed for eligibility. Ultimately, 33 articles were included in the qualitative synthesis. This review includes the analysis of serum levels of the following trace elements: iron, nickel, molybdenum, phosphorus, lead, chromium, antimony, uranium, magnesium, aluminum, zinc, copper, selenium, calcium, and manganese. Currently, there is no consistency regarding serum trace element levels in schizophrenic patients. Thus, it cannot be considered as a reliable prognostic or diagnostic marker of schizophrenia. However, it can be assumed that altered concentrations of those elements are crucial regarding the onset and exaggeration of either psychotic or negative symptoms or cognitive dysfunctions.

A review and analysis of the components of potentially effective perinatal mental health interventions for infant development and mother-infant relationship outcomes

Children of mothers with serious mental health difficulties are at increased risk of developing mental health difficulties themselves in their own lifetime. Specialist interventions delivered in perinatal mental health services offer an opportunity to support the infant's development and long-term mental health. This review aimed to systematically evaluate the shared elements of successful perinatal mental health interventions that underpin improved outcomes for infants whose mothers experience perinatal mental health difficulties. Nine electronic databases were searched comprehensively for relevant controlled studies of perinatal mental health interventions, and a narrative synthesis undertaken to assess whether statistically significant benefits were noted. Sixteen studies, trialing 19 interventions, were analyzed using a narrative approach and grouped according to reported effectiveness. Eight interventions demonstrated significant improvements in infant outcomes and/or mother-infant relationship outcomes and were used to inform the analysis of the included interventions' components. While the interventions identified were diverse, there were common components which potentially underpin successful interventions for infants whose mothers are experiencing mental health difficulties, including: facilitation of positive Mother×Infant interactions; helping mothers to understand their infant's perspective or inner world; and the use of video feedback.

General medical conditions and mortality in women with postpartum psychiatric disorders

BACKGROUND

Psychiatric patients have an increased risk of general medical conditions and mortality, but no study has systematically explored these outcomes among women with mental disorders following childbirth (postpartum psychiatric disorders: PPD). Therefore, we aimed to investigate the risk of subsequent general medical conditions and mortality in women with a broad spectrum of PPD.

METHODS

This register-based cohort study followed all Danish women born after January 1, 1960, until January 1, 2016. The exposure of interest was (i) mild-moderate PPD: first-ever prescription of psychotropic medication (ATC codes: N03-N07) and (ii) severe PPD: first-ever in- or out-patient contact to a psychiatric facility, both within six months postpartum. Outcomes of interest were (i) hospital-registered chronic medical conditions and (ii) mortality from natural and unnatural causes. We included 1 841 949 women representing 22 615 310 person-years at risk.

RESULTS

Among 15 852 women with mild-moderate PPD and 4266 women with severe PPD, we found a higher risk of any subsequent general medical condition (mild-moderate PPD: IRR 1.25; 95% CI 1.20-1.31 and severe PPD: IRR 1.35; 95% CI: 1.24-1.48) when compared to the female background population. Mortality from both natural and unnatural causes was higher in both groups: Mild-moderate PPD: natural causes MRR 1.37; 95% CI: 1.17-1.61; unnatural causes MRR 1.52; 95% CI: 1.10-2.11, and severe PPD: natural causes MRR 1.42; 95% CI 1.02-2.00, and unnatural causes MRR 5.05; 95% CI: 3.40-7.51.

CONCLUSIONS

This first overview of general medical prognosis in PPD shows that women at either end of the spectrum are at increased risk of subsequent chronic medical conditions and overall mortality.

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.

Early styles of interaction in mother-twin infant dyads and maternal mental health

Transition to parenthood is considered a critical process for mothers of twins. There are, however, few studies on the subject. This study aims to evaluate the differences between mother-twin infant dyads and mother-singleton infant dyads with regard to maternal depression, anxiety, parenting stress, and the quality of mother-infant interaction. Mothers of twin infants (N = 40) were compared to mothers of singletons (N = 72). At infant 3 months, maternal depression, anxiety, and parenting stress were assessed via a questionnaire and styles of interaction with the Care-Index. The results indicated that mothers of twins (vs mothers of singletons) had significantly higher state anxiety and higher scores on the Difficult Child Scale of the Parenting Stress Index at infant 3 months. No significant differences between the two groups were found with regard to maternal depression. Mothers of twins had significantly lower sensitivity and were more unresponsive than mothers of singletons. Twin infants had significantly more difficult and compliant behaviours than singleton infants. Assisted reproductive treatment (ART) and prematurity had no effect on any of the examined variables. State anxiety was shown to partially mediate the relationship between twin parenthood and maternal sensitivity and to completely mediate the relationship between twin parenthood and infant difficult style. Maternal unresponsiveness was shown to be exclusively linked to being the parent of twins. The study shows that twin parenthood has a significant effect on maternal mental health and on the quality of mother-infant interaction and highlights the importance of early prevention programmes for twin parents.

Associations between commonly used patient-reported outcome tools in postpartum depression clinical practice and the Hamilton Rating Scale for Depression

The objective of this study is to explore the associations between the patient-reported Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ)-9 and clinician-reported 17-item Hamilton Depression Rating Scale (HAMD-17) in order to facilitate clinical decision-making. An integrated efficacy dataset of three randomized placebo-controlled trials (NCT02614547, NCT02942004, and NCT02942017) evaluating brexanolone injection, a neuroactive steroid chemically identical to allopregnanolone, in women with postpartum depression was used for this post hoc analysis. Data were pooled across treatment arms. Associations were assessed at day 30 (end-of-trial follow-up). Pearson correlation assessed the relationship between EPDS and PHQ-9 item and total scores and HAMD-17 total score. Cohen's kappa assessed agreement of EPDS remission (score < 10) and PHQ-9 remission (score < 5) with HAMD-17 remission (score ≤ 7). Ordinary least squares (OLS) regression models were used to develop equations estimating HAMD-17 total scores from EPDS and PHQ-9 scores, respectively. The total scores showed large correlations (HAMD-17/EPDS: r = 0.71, p < 0.001; HAMD-17/PHQ-9: r = 0.75, p < 0.001). Individual EPDS and PHQ-9 items significantly correlated (r= 0.35 to 0.67, all p < 0.001) with HAMD-17 total score. EPDS had 79% sensitivity and 67% specificity to detect HAMD-17 remission; corresponding estimates for PHQ-9 were 76% and 78%. OLS models yielded the following equations: HAMD-17 total = 2.66 + (EPDS total × 0.87) and HAMD-17 total = 3.99 + (PHQ-9 total × 0.97). There were large and statistically significant associations between patient-reported outcomes (EPDS, PHQ-9) and clinician-reported outcomes (HAMD-17) as clinical improvements were associated with patient-reported symptom improvement. These results provide tools to help translate clinical trial data to clinical practice, thus aiding shared decision-making for this critical population.

Intraoperative ketamine for reduction in postpartum depressive symptoms after cesarean delivery: A double-blind, randomized clinical trial

BACKGROUND

Postpartum depression (PPD) is a common mental disease happens in perinatal period. Ketamine as an anesthesia and analgesia drug has been used for a long time. In recent years, ketamine is proved to have an antidepression effect with a single administration. We hypothesized that intraoperative ketamine can reduce postpartum depressive symptoms after cesarean delivery.

METHODS

In a randomized, double-blind, placebo-controlled study trail, healthy women scheduled for cesarean delivery were randomly assigned to receive intravenous ketamine (0.25 mg/kg diluted to 5 ml with 0.9% saline) or placebo (5 ml of 0.9% saline) within 5 min following clamping of the neonatal umbilical cord. The primary outcome was the degree of postpartum depressive symptoms, which was evaluated by Edinburgh Postnatal Depression Scale (EPDS, a threshold of 9/10 was used) at 1 week, 2 weeks, and 1 month after delivery. The secondary outcome was the numerical rating scale (NRS) score of pain at 2 days postpartum. This trail is registered in the Chinese Clinical Trial Registry, number ChiCTR1900022464.

RESULTS

Between 26 January 2019 and 15 July 2019, 502 subjects were screened and 330 were randomly allocated: 165 (50%) to the ketamine group and 165 (50%) to the placebo group. There were significant differences in the degree of postpartum depressive symptoms between subjects in the ketamine group and the placebo group at 1 week postpartum (13.1% vs. 22.6%, respectively; p = .029). However, no difference was found between subjects in the two groups at 2 weeks (11.8% vs. 16.8%, respectively; p = .209) and 1 month postpartum (10.5% vs. 14.2%, respectively; p = .319). The NRS score of wound pain (3.0 ± 0.9 vs. 4.0 ± 1.0, respectively; p < .001) and uterine contraction pain (3.0 ± 0.9 vs. 4.1 ± 0.9, respectively; p < .001) was lower in the ketamine group at 2 days postpartum compared with placebo group. The prevalence of headache, hallucination, and dizziness was higher in the ketamine group than the placebo group during the operation.

CONCLUSIONS

Operative intravenous ketamine (0.25 mg/kg) can reduce the postpartum depressive symptoms for 1 week. The long-time effect is remained to be seen.

Self-harm in women with postpartum mental disorders

BACKGROUND

Women suffering from first onset postpartum mental disorders (PPMD) have a highly elevated risk of suicide. The current study aimed to: (1) describe the risk of self-harm among women with PPMD and (2) investigate the extent to which self-harm is associated with later suicide.

METHODS

We conducted a register-based cohort study linking national Danish registers. This identified women with any recorded first inpatient or outpatient contact to a psychiatric facility within 90 days after giving birth to their first child. The main outcome of interest was defined as the first hospital-registered episode of self-harm. Our cohort consisted of 1 202 292 women representing 24 053 543 person-years at risk.

RESULTS

Among 1554 women with severe first onset PPMD, 64 had a first-ever hospital record of self-harm. Women with PPMD had a hazard ratio (HR) for self-harm of 6.2 (95% CI 4.9-8.0), compared to mothers without mental disorders; but self-harm risk was lower in PPMD women compared to mothers with non-PPMD [HR: 10.1, (95% CI 9.6-10.5)] and childless women with mental disorders [HR: 9.3 (95% CI 8.9-9.7)]. Women with PPMD and records of self-harm had a significantly greater risk for later suicide compared with all other groups of women in the cohort.

CONCLUSIONS

Women with PPMD had a high risk of self-harm, although lower than risks observed in other psychiatric patients. However, PPMD women who had self-harmed constituted a vulnerable group at significantly increased risk of later suicide.

Psychological status of postpartum women under the COVID-19 pandemic in Japan

Under the COVID-19 (Coronavirus Disease 2019) pandemic, limitations are known to cause some psychosocial problems. We compared the results of mental screening of the postpartum women conducted during the COVID-19 epidemic with those at the same period last year. Based on the results, the worse mother-infant bonding was suspected at 1 month after birth under the COVID-19 pandemic.

Pushing beyond the silos: the obstetrician's role in perinatal depression care

Perinatal depression is one of the most common medical complications during and after pregnancy, occurring in up to 20% of new mothers in the USA. It can have both short- and long-term effects on the mother, child, and family. Multiple etiologies have been proposed for perinatal depression, and there are many reported genetic, epigenetic, environmental, socioeconomic, and psychosocial risk factors. Perinatal depression can be treatable but remains underdiagnosed and undertreated for a variety of reasons, including inconsistent clinical definitions, inconsistent screening, social stigma, and logistic/financial barriers to evidence-based treatments. The diagnosis and treatment of perinatal depression can be complicated by the frequent need for coordination among multiple care providers before and after childbirth. Among the care providers who may encounter perinatal depression, obstetricians are uniquely positioned to provide anticipatory guidance at regular prenatal visits and to identify symptoms and coordinate care, as they follow patients at multiple encounters throughout pregnancy and into the postpartum period. While obstetricians are already among the most common healthcare professionals who diagnose and treat perinatal depression, an opportunity for obstetricians to enhance early detection and treatment of perinatal depression exists. Professional societies and patient advocacy organizations support implementation of universal screening during the perinatal period, and validated clinical tools can detect nearly 50% more patients than more informal methods. This review outlines our current knowledge of perinatal depression and highlights the vital role of obstetricians in screening and treatment.

Cost-Effectiveness of Brexanolone Versus Selective Serotonin Reuptake Inhibitors for the Treatment of Postpartum Depression in the United States

BACKGROUND

Brexanolone injection (BRX) was approved by the FDA in 2019 for the treatment of adult patients with postpartum depression (PPD), but its cost-effectiveness has not yet been evaluated.

OBJECTIVE

To estimate the cost-effectiveness of BRX compared with treatment with selective serotonin reuptake inhibitors (SSRIs) for PPD.

METHODS

We projected costs (2018 U.S. dollars) and health (quality-adjusted life-years [QALYs]) for mothers treated with BRX or SSRIs and their children. A health state transition model projected clinical and economic outcomes for mothers based on the Edinburgh Postnatal Depression Scale, from a U.S. payer perspective. The modeled population consisted of adult patients with moderate to severe PPD, similar to BRX clinical trial patients. Short-term efficacy for BRX and SSRIs came from an indirect treatment comparison. Long-term efficacy outcomes over 4 weeks, 11 years (base case), and 18 years were based on results from an 18-year longitudinal study. Maternal health utility values came from analysis of trial-based short-form 6D responses. Other inputs were derived from the literature.

RESULTS

The incremental cost-effectiveness ratio for BRX versus SSRIs was $106,662 per QALY gained over an 11-year time horizon. Drug and administration costs for BRX averaged $38,501, compared with $25 for SSRIs over the studied time horizon. Maternal total direct medical costs averaged $65,908 in the BRX arm, compared with $73,653 in the SSRI arm. BRX-treated women averaged 6.230 QALYs compared with 5.979 QALYs for the SSRI arm. Adding partner costs and utilities in a sensitivity analysis further favored BRX. Results were sensitive to the severity of PPD at baseline and the model time horizon. Probabilistic sensitivity analyses indicated that BRX was cost-effective at the $150,000-per-QALY threshold with 58% probability.

CONCLUSIONS

Analysis using a state transition model showed BRX to be a cost-effective therapy compared with SSRIs for treating women with PPD.

DISCLOSURES

This study was funded by Sage Therapeutics, Cambridge, MA. Eldar-Lissai, Gerbasi, and Hodgkins are employees of Sage Therapeutics and own stock or stock options in the company. Gerbasi also reports previous employment with Policy Analysis Inc. Cohen contributed to this work as an independent consultant. Meltzer-Brody has a sponsored clinical research agreement with Sage Therapeutics to the University of North Carolina, as well as a sponsored research agreement from Janssen to the University of North Carolina, unrelated to this work. Meltzer-Brody has also received personal consulting fees from Cala Health and MedScape, unrelated to this work. Johnson, Chertavian, and Bond are employees of Medicus Economics, which was paid fees by Sage to conduct the research for this study. Study findings do not necessarily represent the views of CEVR or Tufts Medical Center.

Postpartum maternal distress: a multidimensional illness requiring a multilevel, multidiscipline response

Australia's federal, state, territory and local governments all have responsibilities, often overlapping, for policy and delivery of primary mental health care to postpartum women. Identification and treatment of postpartum distress is carried out by a broad range of professionals from diverse disciplines. Although there is evidence to show that anxiety and stress are important aspects of postpartum distress, substantially greater emphasis has been given to identification and treatment of depression. In addition, relatively little attention has been given to incorporating positive and negative social experiences in healthcare policy and practice. This study aimed to extend the postpartum literature by: (1) comparing the levels of depression, anxiety and stress (i.e. distress indicators) in a non-clinical sample of postpartum mothers to those in the general non-clinical population; (2) comparing the prevalence of anxiety and stress to that of depression in postpartum mothers; and (3) examining the consequences of negative social exchange, alongside perceived social support, on postpartum distress indicators. A self-report survey was completed by 242 postpartum women assessing levels of perceived social support, frequency of negative social exchange and distress indicators. Postpartum mothers were found to have significantly higher depression, anxiety and stress than the general population, and had anxiety and stress levels that were similar in severity to depression. In addition, both negative social exchanges and perceived social support were found to be important for postpartum depression, anxiety and stress. These findings suggest that Australia's primary postpartum mental health care policy and practice guidelines, delivered through a broad range of professionals, may benefit from giving anxiety and stress equal weight to depression and by embracing the important effects, for good and for ill, of positive and negative social interactions.

Pregnancy, postpartum and parity: Resilience and vulnerability in brain health and disease

Risk and resilience in brain health and disease can be influenced by a variety of factors. While there is a growing appreciation to consider sex as one of these factors, far less attention has been paid to sex-specific variables that may differentially impact females such as pregnancy and reproductive history. In this review, we focus on nervous system disorders which show a female bias and for which there is data from basic research and clinical studies pointing to modification in disease risk and progression during pregnancy, postpartum and/or as a result of parity: multiple sclerosis (MS), depression, stroke, and Alzheimer's disease (AD). In doing so, we join others (Shors, 2016; Galea et al., 2018a) in aiming to illustrate the importance of looking beyond sex in neuroscience research.

Oxytocin during breastfeeding and maternal mood symptoms

This study aimed to quantify the relationship between postpartum depression and anxiety, oxytocin, and breastfeeding. We conducted a longitudinal prospective study of mother-infant dyads from the third trimester of pregnancy to 12 months postpartum. A sample of 222 women were recruited to complete the Beck Depression Inventory II and Spielberger State-Trait Anxiety Inventory-state subscale, participate in observed infant feeding sessions at 2 and 6 months postpartum, and provide venous blood samples during feeding. Maternal venous oxytocin levels in EDTA-treated plasma and saliva were determined by enzyme immunoassay with extraction and a composite measure of area under the curve (AUC) was used to define oxytocin across a breastfeeding session. Linear regression was used to estimate associations between postpartum depression and anxiety as predictors and oxytocin AUC during breastfeeding as the outcome at both 2 and 6 months postpartum. Mixed models accounting for correlations between repeated oxytocin measures were used to quantify the association between current depression and/or anxiety symptoms and oxytocin profiles during breastfeeding. We found no significant differences in oxytocin AUC across a feed between depressed or anxious women and asymptomatic women at either 2 or 6 months postpartum. Repeated measures analyses demonstrated no differences in oxytocin trajectories during breastfeeding by symptom group but possible differences by antidepressant use. Our study suggests that external factors may influence the relationship between oxytocin, maternal mood symptoms, and infant feeding.

Perinatal psychological well-being in women with zero postnatal anxiety-depressive symptoms scores: a retrospective descriptive study

Background: A total absence of psychological symptoms during pregnancy or postpartum period is not common. Although there are some considerations on zero scores detected by EPDS, no thorough analysis is currently present in the literature of the eventuality and meaning of a total absence of postpartum symptoms following the compilation of two or more self-report symptom questionnaires.Methods: In a sample of 960 Italian women, three groups of 31 subjects are defined retrospectively by scores on the EPDS-GHQ12: women with 'zero', 'lower', and 'higher' postnatal symptomatology. The psychological well-being of these groups was compared as detected in pregnancy and after childbirth by PWB questionnaire.Results: Higher and excessive scores in Environmental mastery dimension connote the profile of women with a total absence of postpartum anxiety-depression symptoms. Positive relations with other dimension were less characterising, but it should be noted as a distinctive trait in the 'zero' symptoms postnatal symptomatology group. In the same 'zero' group, the scores of the six PWB questionnaire dimensions - except Personal growth - are all higher than the scores obtained by women in the general population.Conclusion: The atypical self-reported perinatal mood condition present in the 'zero' symptoms group have currently unknown clinical significance.

Population-Based Assessment of the Recurrence Risk of Postpartum Mental Disorders: Will It Happen Again?

This study examines the frequency of postpartum mental disorders in women who are primiparous and multiparous.

Eating Disorders During Gestation: Implications for Mother's Health, Fetal Outcomes, and Epigenetic Changes

Introduction: Eating disorders (EDs) have increased globally in women of childbearing age, related to the concern for body shape promoted in industrialized countries. Pregnancy may exacerbate a previous ED or conversely may be a chance for improving eating patterns due to the mother's concern for the unborn baby. EDs may impact pregnancy evolution and increase the risk of adverse outcomes such as miscarriage, preterm delivery, poor fetal growth, or malformations, but the knowledge on this topic is limited. Methods: We performed a systematic review of studies on humans in order to clarify the mechanisms underpinning the adverse pregnancy outcomes in patients with EDs. Results: Although unfavorable fetal development could be multifactorial, maternal malnutrition, altered hormonal pathways, low pre-pregnancy body mass index, and poor gestational weight gain, combined with maternal psychopathology and stress, may impair the evolution of pregnancy. Environmental factors such as malnutrition or substance of abuse may also induce epigenetic changes in the fetal epigenome, which mark lifelong health concerns in offspring. Conclusions: The precocious detection of dysfunctional eating behaviors in the pre-pregnancy period and an early multidisciplinary approach comprised of nutritional support, psychotherapeutic techniques, and the use of psychotropics if necessary, would prevent lifelong morbidity for both mother and fetus. Further prospective studies with large sample sizes are needed in order to design a structured intervention during every stage of pregnancy and in the postpartum period.

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.

Improving Mental Health for the Mother-Infant Dyad by Nutrition and the Maternal Gut Microbiome

Perinatal mood and anxiety disorders (PMAD) have significant negative impacts on mother and child, yet treatments are limited. Adequate nutrition during the perinatal period is essential to maternal and infant health, including maternal mental health and the child's neurologic and neuropsychiatric development. Nutrition holds promise to improve prevention and treatment of PMAD. The ability to manipulate the gut microbiota composition and structure through host nutrition and to harness the gut microbes for improved individualized nutrition may be an important new direction for prevention and treatment of PMAD, thus improving the mental health of mother and child.

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

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

Peripartum depression and infant care, sleep and growth

Peripartum depression is a common, serious complication in mothers. To assess the influence of infant care, sleep and growth on the risk of peripartum depression, 1,271 mothers of healthy one-month-old infants completed comprehensive questionnaires including the Edinburgh Postnatal Depression Scale. Relationships between high depression scores and variables related to infants’ care, sleep and growth were assessed adjusting for other variables. High depression scores were found in 233 mothers, which were associated with variables related to infants’ care (poor satisfaction with infant care support, p < 0.001; mothers’ passive response to night-time fussing, p = 0.001), sleep (dim bedroom lighting, p < 0.05; short sleep duration, p < 0.05) and growth (poor weight gain, p < 0.05), as well as maternal variables (primiparas, p < 0.001; poor income satisfaction, p < 0.001; poor sleep satisfaction, p < 0.001; daytime sleepiness, p = 0.001). Considering the observed association between high depression scores and infants’ care, sleep and growth, a multidisciplinary approach accounting for infant care would be required to prevent peripartum depression.

The association between childbirth experience and mother's parenting stress: The mediating role of anxiety and depressive symptoms

Childbirth is one of the most significant experiences in women's lives. A bad experience could lead to psychological distress, including severe disease. This experience has a significant impact not only on the mother's well-being, but also on her first interactions with the baby. The present study thus had two aims: 1) investigate the association between the childbirth experience and parenting stress; and 2) analyze if this relation can be mediated by the woman's psychological well-being (anxiety and depressive symptoms). One hundred fifty-eight Italian primiparous women, with a single pregnancy, recruited between January 2016 and December 2016, completed three months after delivery the following scales: Wijma Delivery Experience Questionnaire; State-Trait Anxiety Inventory; Edinburgh Postnatal Depression Scale and Parenting Stress Index (Short Form). Data were analyzed through path analyses. Results revealed that the birth experience was not directly associated with parenting stress. The final model confirmed that the childbirth experience was related to parenting stress through the full mediation of anxiety and depressive symptoms. These findings highlight the importance of making mothers' childbirth experience as positive as possible, considering the crucial impact of this experience not only on their global functioning but also on their first relationships with the baby.

Genome-wide gene expression in a pharmacological hormonal transition model and its relation to depressive symptoms

OBJECTIVES

Sensitivity to sex-steroid hormone fluctuations may increase risk for perinatal depression. We aimed to identify genome-wide biological profiles in women demonstrating sensitivity to pharmacological sex-hormone manipulation with gonadotrophin-releasing hormone agonist (GnRHa).

METHODS

Longitudinal gene expression (Illumina Human HT12.v4) and DNA methylation data (Infinium HumanMethylation450K BeadChip) from 60 women (30 GnRHa, 30 placebo) were generated (Trial ID: NCT02661789). Differences between baseline and two follow-up points (initial stimulation- and subsequent early suppression phase) in the biphasic ovarian hormone response to GnRHa were assessed using linear mixed effects models.

RESULTS

Genome-wide analysis revealed 588 probes differentially expressed from GnRHa intervention to first stimulatory phase follow-up (intervention group × time) after 10% fdr multiple testing correction. Of these, 54% genes were also significantly associated with estradiol changes over time (proxy for GnRHa response magnitude), 9.5% were associated with changes in depressive symptoms, and 38% were associated with changes in neocortical serotonin transporter binding. The genes were implicated in TGF beta signaling, adipogenesis, regulation of actin cytoskeleton, and focal adhesion pathways and enriched for DNA methylation changes (P = 0.006).

CONCLUSIONS

These findings point toward an altered peripheral blood transcriptomic landscape in a pharmacological model of sex-hormone-induced depressive symptoms.

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.

The maternal reward system in postpartum depression

The experience of motherhood is most often emotionally positive and rewarding, but for many new mothers suffering from postpartum depression (PPD), this is not the case. Preclinical and clinical research has sought to uncover brain changes underlying PPD in order to gain a better understanding of how this disorder develops. This review focuses on the mesolimbic dopamine system, particularly the ventral tegmental area-nucleus accumbens pathway which has been implicated in the regulation of critical functions disrupted in PPD including mood, motivation, and mothering. Specifically, we discuss normative changes in the mesolimbic system during motherhood in both rodents and humans and how these are impacted in PPD. We also consider modulation of mesolimbic dopamine by the hypothalamic neuropeptide oxytocin and how oxytocin-dopamine interactions regulate mood and mothering during the postpartum period. In addition to providing an overview of reward mechanisms in PPD, our goal is to highlight open questions which warrant further research.

The international postpartum depression: action towards causes and treatment (PACT) consortium

The International Postpartum depression: Action towards Causes and Treatment (PACT) Consortium was founded with the overarching goal of creating an international perinatal psychiatry consortium to conduct novel investigations with large sample sizes to understand the genetic signature of perinatal mood disorders. PACT uses a collaborative and team science approach that includes investigators across 19 institutions and seven continents. The large sample sizes allow for statistically rigorous analyses to investigate perinatal psychiatric disorders, with an initial focus on postpartum depression (PPD). Our current aims are to identify clinical sub-types of PPD that contribute diagnostic heterogeneity, and to elucidate the genetic basis of PPD by conducting the first large genome-wide association study of PPD. To accomplish the latter aim, we are partnering with the Major Depressive Disorder Working Group of the Psychiatric Genomics Consortium. To date, our consortium members have recruited 17,912 participants and 11,344 participants have been identified using the PPD ACT mobile app, of which 8,432 are PPD cases. Ultimately, we hope this approach will improve detection, diagnosis, and treatment of women who suffer from perinatal psychiatric disorders.

A role for the microbiome in mother-infant interaction and perinatal depression

Perinatal depression is a significant public health problem, due to its negative impact on maternal well-being and long-term adverse effects for children. Mother-infant interaction and maternal responsiveness and sensitivity are a hypothesized mechanism by which perinatal depression effects child development, and increasing research in the microbiota-gut-brain axis may provide a new avenue of investigation. There is limited efficacy for treatment of perinatal depression for improving the mother-infant relationship and child outcomes. The maternal microbiota may be the basis of child outcomes through foetal programming and sharing of microbes between mother and infant. There is evidence that less diversity of the intestinal microbial community is associated with neuropsychiatric disorders, including depression and anxiety in mothers and offspring. Assessing the maternal and child's microbial communities may be an important missing component in mother-infant attachment-based therapies during treatment of perinatal depression. Probiotics and prebiotics require further research as additions to mother-infant interventions. Further research may enable identification of bacterial genes that indicate specific pathways that could be targeted to improve outcomes for mother and child.