The efficacy of early iron supplementation on postpartum depression, a randomized double-blind placebo-controlled trial

Wellbeing Forecasting in Postpartum Anemia Patients

Postpartum anemia is a very common maternal health problem and remains a persistent public health issue globally. It negatively affects maternal mood and could lead to depression, increased fatigue, and decreased cognitive abilities. It can and should be treated by restoring iron stores. However, in most health systems, there is typically a six-week gap between birth and the follow-up postpartum visit. Risks of postpartum maternal complications are usually assessed shortly after birth by clinicians intuitively, taking into account psychosocial and physical factors, such as the presence of anemia and the type of iron supplementation. In this paper, we investigate the possibility of using machine-learning algorithms to more reliably forecast three parameters related to patient wellbeing, namely depression (measured by Edinburgh Postnatal Depression Scale-EPDS), overall tiredness, and physical tiredness (both measured by Multidimensional Fatigue Inventory-MFI). Data from 261 patients were used to train the forecasting models for each of the three parameters, and they outperformed the baseline models that always predicted the mean values of the training data. The mean average error of the elastic net regression model for predicting the EPDS score (with values ranging from 0 to 19) was 2.3 and outperformed the baseline, which already hints at the clinical usefulness of using such a model. We further investigated what features are the most important for this prediction, where the EDPS score and both tiredness indexes at birth turned out to be by far the most prominent prediction features. Our study indicates that the machine-learning model approach has the potential for use in clinical practice to predict the onset of depression and severe fatigue in anemic patients postpartum and potentially improve the detection and management of postpartum depression and fatigue.

Dietary interventions for perinatal depression and anxiety: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Dietary interventions are a widely available intervention for depression and anxiety among pregnant and/or postpartum (i.e., perinatal) persons but their effectiveness is not well known.

OBJECTIVE

We performed a systematic review and meta-analysis to assess the effectiveness of dietary interventions for the treatment of perinatal depression and/or anxiety.

DESIGN

We searched Medline, EMBASE, PsycINFO, CINAHL, and Web of Science from their inception to November 2, 2022. Studies were included if they were available in English and examined the effectiveness of a dietary intervention for perinatal depression and/or anxiety in a randomized controlled trial.

RESULTS

Our search identified 4,246 articles, 36 of which were included and 28 were eligible for meta-analysis. Random effects meta-analyses were performed. Polyunsaturated fatty acids (PUFAs) were not found to improve symptoms of perinatal depression compared to control conditions (SMD -0.11; 95% CI -0.26 to 0.04). These results did not change when examined during pregnancy or the postpartum period separately, nor did they vary according to fatty acid ratio. Elemental metals (iron, zinc, and magnesium) were also not found to be superior to placebo (SMD, -0.42; 95% CI, -1.05 to 0.21), though, vitamin D yielded a small to medium effect size improvements (SMD, -0.52; 95% CI, -0.84 to -0.20) in postpartum depression. Iron may help in those with confirmed iron deficiency. Narrative synthesis was performed for studies ineligible for meta-analyses.

CONCLUSIONS

Despite their widespread popularity, PUFAs and elemental metals do not appear to effectively reduce perinatal depression. Vitamin D taken in doses of 1800 to 3500 International Units (IU) per day may have some promise. Additional high-quality, large-scale randomized controlled trials (RCTs) are needed to determine the true effectiveness of dietary interventions on perinatal depression and/or anxiety.

PROSPERO REGISTRATION DATE AND NUMBER

July 5^th 2020, CRD42020208830.

Increased BDNF and hippocampal dendritic spine density are associated with the rapid antidepressant-like effect of iron-citalopram and iron-imipramine combinations in mice

Iron supplementation previously demonstrated antidepressant-like effects in post-partum rats. The present study evaluates the possible synergistic antidepressant effect of sub-therapeutic dose of iron co-administered with citalopram or imipramine in female Institute of Cancer Research mice. Depression-like symptoms were induced in the forced swim (FST), tail suspension (TST), and open space swim (OSST) tests while open field test (OFT) was used to assess locomotor activity. Mice (n=8) received iron (0.8- 7.2 mg/kg), citalopram (3-30 mg/kg), imipramine (3-30 mg/kg), desferrioxamine (50 mg/kg) or saline in the single treatment phase of each model and subsequently a sub-therapeutic dose of iron co-administered with citalopram or imipramine. Assessment of serum BDNF and dendritic spine density was done using ELISA and Golgi staining techniques respectively. Iron, citalopram and imipramine, unlike desferrioxamine, reduced immobility score in the TST, FST and OSST without affecting locomotor activity, suggesting antidepressant-like effect. Sub-therapeutic dose of iron in combination with citalopram or imipramine further enhanced the antidepressant-like effect, producing a more rapid effect when compared to the iron, citalopram or imipramine alone. Iron, citalopram and imipramine or their combinations increased serum BDNF concentration, hippocampal neuronal count and dendritic spine densities. Our study provides experimental evidence that iron has antidepressant-like effect and sub-therapeutic dose of iron combined with citalopram or imipramine produces more rapid antidepressant-like effect. We further show that iron alone or its combination with citalopram or imipramine attenuates the neuronal loss associated with depressive conditions, increases dendritic spines density and BDNF levels. These finding suggest iron-induced neuronal plasticity in the mice brain.

Gestational anemia and maternal antenatal and postpartum psychological distress in a prospective FinnBrain Birth Cohort Study

BACKGROUND

Gestational anemia, most commonly caused by iron deficiency, may increase the risk of maternal anxiety and depression and have a potentially far-reaching impact on mother's and newborn's health. Several mechanisms, such as effects of iron deficiency on cerebral neurotransmitter metabolism, have been suggested. None of the earlier studies have assessed the association between gestational anemia and depression, anxiety and pregnancy-related anxiety simultaneously.

METHODS

Women, participating in the FinnBrain Birth Cohort Study and attending maternity welfare clinics in Turku, whose hemoglobin (Hb) values during pregnancy were available were included in this study (n = 1273). The study group consisted of 301 women with Hb levels < 11.0 g/dL at any time during pregnancy, and 972 women with Hb ≥ 11.0 g/dL were included in the control group. Symptoms of depression, anxiety, and pregnancy-related anxiety were assessed using the Edinburgh Postnatal Depression Scale (EPDS), Symptom Checklist-90 (SCL), and Pregnancy-Related Anxiety Questionnaire (PRAQ) questionnaires at 14, 24, and 34 gestational weeks, and EPDS and SCL were also performed 3 and 6 months postpartum.

RESULTS

Gestational anemia was not associated with an increased risk of depression either prenatally or postpartum when the analyses were adjusted for maternal age at birth, parity, smoking during pregnancy, maternal education, and gestational age. However, a weak connection was found between gestational anemia and prenatal anxiety in the early pregnancy. Furthermore, the analysis between women with Hb < 10.0 g/dL and those with Hb ≥ 10.0 g/dL showed an association between gestational anemia and anxiety in the late pregnancy, but otherwise no difference in psychological distress was found.

CONCLUSIONS

No evidence supporting the association between gestational anemia and antenatal or postpartum depression was found. However, a weak connection between gestational anemia and antenatal anxiety was observed. This finding needs further investigation to establish timing and investigate causality.

Environmental risk factors, protective factors, and biomarkers for postpartum depressive symptoms: an umbrella review

We performed an umbrella review on environmental risk/protective factors and biomarkers for postpartum depressive symptoms to establish a hierarchy of evidence. We systematically searched PubMed, Embase, and the Cochrane Database of Systematic Reviews from inception until 12 January 2021. We included systematic reviews providing meta-analyses related to our research objectives. Methodological quality was assessed by AMSTAR 2, and the certainty of evidence was evaluated by GRADE. This review was registered in PROSPERO (CRD42021230784). We identified 30 articles, which included 45 environmental risk/protective factors (154,594 cases, 7,302,273 population) and 9 biomarkers (2018 cases, 16,757 population). The credibility of evidence was convincing (class I) for antenatal anxiety (OR 2.49, 1.91-3.25) and psychological violence (OR 1.93, 1.54-2.42); and highly suggestive (class II) for intimate partner violence experience (OR 2.86, 2.12-3.87), intimate partner violence during pregnancy (RR 2.81, 2.11-3.74), smoking during pregnancy (OR 2.39, 1.78-3.2), history of premenstrual syndrome (OR 2.2, 1.81-2.68), any type of violence experience (OR 2.04, 1.72-2.41), primiparity compared to multiparity (RR 1.76, 1.59-1.96), and unintended pregnancy (OR 1.53, 1.35-1.75).

Gestational iron supplementation reverses depressive-like behavior in post-partum Sprague Dawley rats: Evidence from behavioral and neurohistological studies

Background

Postpartum depression is a mood disorder that affects about 9–20% of women after child birth. Reports suggest that gestational iron deficiency can cause a deficit in behavioral, cognitive and affective functions and can precipitate depressive symptoms in mothers during the postpartum period. The present study examined the effect of iron supplementation on depressive behavior during postpartum period in a rat model.

Method

Female Sprague-Dawley rats were crossed. Pregnant rats received iron, fluoxetine, desferrioxamine or vehicle throughout the period of gestation. During the postpartum period, mothers from all groups were taken through the open field test (OFT), forced swim test (FST), novelty-induced hypophagia (NIH) and sacrificed for histological examination of the brains.

Results

Results showed that rats treated with iron-chelating agent, desferrioxamine, and vehicle during gestation exhibited increased immobility scores in the FST, increased latency to feed and reduced feeding in the NIH with corresponding decreased number of neurons and dendritic branches in the cortex of the brain. These depression-related effects were attenuated by perinatal iron supplementation which showed decreased immobility scores in the FST comparable to rats treated with fluoxetine, a clinically effective antidepressant. Iron treatment also decreased latency to feeding while increasing feeding behavior in the NIH. Iron-treated dams had a higher number of neurons with dendritic connections in the frontal cortex compared to vehicle- and desferrioxamine-treated groups.

Conclusion

The results suggest that, iron supplementation during gestation exerts an antidepressant-like effect in postpartum Sprague-Dawley rats, attenuates neuronal loss associated with depression and increases dendritic spine density.

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Iron supplementation during gestation exerts an antidepressant-like effect in postpartum Sprague-Dawley rats.

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Iron supplementation during gestation attenuates neuronal loss associated with depression.

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Iron-treated dams had a higher number of neurons with dendritic connections in the frontal cortex.

Is iron deficiency a risk factor for postpartum depression? A case-control study in the Gaza Strip, Palestine

OBJECTIVE

This study aims to investigate the association between iron body status and postpartum depression (PPD) among mothers during the postpartum period.

DESIGN

This is a case-control study.

SETTING

Governmental primary health care centres in the Gaza Strip, Palestine.

PARTICIPANTS

This study involved 300 mothers a month after delivery, with one 150 mothers that were recruited in the cases group who were diagnosed with PPD based on Edinburgh Postnatal Depression Scale (EPDS) ≥ 10. The control group included 150 mothers did not have PPD (EPDS < 10). Body iron status is represented by the index of sTfR/log ferritin.

RESULTS

Among PPD mothers, 43·3 % had low ferritin level v. 15·3 % for controls (P < 0·001) and cases v. controls difference in mean Hb level was -0·61 (95 % CI -0·86, -0·35). The results of the multiple logistic regression reported that there is a statistically significant association between PPD and the body iron status existed, as mothers who suffered from iron deficiency (ID) were three times more likely to have PPD (ORadj 3·25; P = 0·015). Furthermore, the results of the final regression model showed that the other factors that can lead to PPD are absence of psychological guidance services (ORadj 8·54; P = 0·001), suffering from undesired feeling in the last pregnancy (ORadj 1·77; P = 0·034), in addition to having one of the mental health disorders in the last pregnancy (P = 0·001).

CONCLUSION

Body iron status might be a risk factor for postpartum depression and other possibilities of reverse causality may worsen the condition.

The Possible Effects of Zinc Supplementation on Postpartum Depression and Anemia

Background and Objectives: The effects of postpartum zinc supplementation are still unclear. Our purpose in this study is to investigate the association between Zn supplementation and postpartum depression, defined by an Edinburgh Postnatal Depression Scale (EPDS) score ≥ 9, and the effect on the hematological status of postpartum women. Materials and Methods: We first investigated whether zinc supplementation affected the perioperative levels of zinc, hemoglobin, and hematocrit in 197 cases who underwent cesarean section and had postpartum anemia. Next, logistic regression analyses were performed on 148 eligible cases to determine the association between zinc supplementation and postpartum depression. Results: Postpartum zinc supplementation significantly improved the status of maternal blood zinc levels and reduced the risk of developing postpartum depression (adjusted odds ratio: 0.249; 95% confidence interval: 0.062–0.988; p = 0.048). Iron supplementation is a standard and effective strategy for treating anemia; however, the combination of oral iron plus zinc supplementation resulted in slightly significant negative effects on postpartum hemoglobin and hematocrit compared to oral iron supplementation only. Conclusions: Postpartum zinc supplementation causes a significant positive effect on postpartum depression (EPDS score ≥ 9). Zinc supplementation had a negative but transient influence on the hematological status in women with postpartum anemia treated with oral iron supplementation; however, the differences were not clinically significant. Thus, we did not regard it as an adverse effect to be considered, and postpartum zinc supplementation may be viewed as beneficial in postpartum women.

The Problem of Malnutrition Associated with Major Depressive Disorder from a Sex-Gender Perspective

Major depressive disorder (MDD) is an incapacitating condition characterized by loss of interest, anhedonia and low mood, which affects almost 4% of people worldwide. With rising prevalence, it is considered a public health issue that affects economic productivity and heavily increases health costs alone or as a comorbidity for other pandemic non-communicable diseases (such as obesity, cardiovascular disease, diabetes, inflammatory bowel diseases, etc.). What is even more noteworthy is the double number of women suffering from MDD compared to men. In fact, this sex-related ratio has been contemplated since men and women have different sexual hormone oscillations, where women meet significant changes depending on the age range and moment of life (menstruation, premenstruation, pregnancy, postpartum, menopause…), which seem to be associated with susceptibility to depressive symptoms. For instance, a decreased estrogen level promotes decreased activation of serotonin transporters. Nevertheless, sexual hormones are not the only triggers that alter neurotransmission of monoamines and other neuropeptides. Actually, different dietary habits and/or nutritional requirements for specific moments of life severely affect MDD pathophysiology in women. In this context, the present review aims to descriptively collect information regarding the role of malnutrition in MDD onset and course, focusing on female patient and especially macro- and micronutrient deficiencies (amino acids, ω3 polyunsaturated fatty acids (ω3 PUFAs), folate, vitamin B12, vitamin D, minerals…), besides providing evidence for future nutritional intervention programs with a sex-gender perspective that hopefully improves mental health and quality of life in women.

Effect of postpartum anaemia on maternal health-related quality of life: a systematic review and meta-analysis

BACKGROUND

Postpartum anaemia remains a persistent and severe public health issue in many parts of the world. Studies have reported mixed findings on the effects of anaemia during the postpartum period on maternal health-related quality of life (HRQoL). We conducted this systematic review to summarise available evidence to inform public health practitioners on whether 1) anaemia negatively impact maternal health-related quality of life and 2) whether iron supplementation in anaemic women can improve maternal HRQoL during the postpartum period.

METHODS

This review's protocol was registered online with PROSPERO (CRD42020206618). We extensively searched Embase, PubMed, Cochrane and Scopus through the HINARI website to identify studies that reported either association or effect of postpartum anaemia on fatigue, depression and mother-child interaction. We restricted our search to studies of human females published in English language from databases inception until August 2020. We followed a Cochrane guideline for reporting systematic reviews and meta-analysis to synthesise data.

RESULTS

Twenty-seven studies were included in this systematic review, with some reporting all three domains (fatigue, depression and mother-child interaction) of HRQoL. Seven observational studies with pooled dichotomous outcomes showed that iron deficient or anaemic women were 1.66 times more likely to experience symptoms of depression than non-anaemic or iron-replete women [RR = 1.66 (95% CI: 1.28; 2.16), I2 = 67.0%, P < 0.01]. In three randomized controlled trials (RCTs), pooled continuous data showed statistically significant reduction in fatigue scores in women who received iron supplementation than the control group [MD: -1.85 (95% CI: -3.04; -0.67), I2 = 65.0%, p < 0.06]. Two of the four included studies showed that anaemic mothers were less responsive and had negative feelings towards their children than non-anaemic mothers.

CONCLUSION

Evidence from this review suggests that postpartum anaemia negatively affects health-related quality of life and that iron replenishment improves both symptoms of fatigue and depression. Nevertheless, it remains unclear whether postpartum anaemia affects mother-child interaction.

The association between intravenous iron for antenatal anemia and postnatal depression: a retrospective cohort study

PURPOSE

Determine if intravenous iron for antenatal anemia is associated with reduced incidence of postnatal depression (PND) within 12 months.

METHODS

This retrospective cohort study included adult women with antenatal anemia (hemoglobin value of < 11.0 g/dL within 3 months before delivery). PND was defined as Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire-9 (PHQ-9) ≥ 10. Data on intravenous iron, lowest hemoglobin concentration, EPDS and PHQ-9 scores, insurance status, history of anxiety, depression, chronic pain, and substance use, obstetric complications, labor analgesia, and mode of delivery were obtained. Standardized mean difference (SMD) was estimated and multivariable logistic regression models were constructed with adjustment for potential confounders with absolute SMD of ≥ 0.1.

RESULTS

Data from 3988 women were analyzed. The 368 (9.2%) women who received intravenous iron therapy had lower antenatal hemoglobin levels, were more likely to be African American or single/widowed women, and more commonly had  Medicaid coverage, repeat cesarean delivery, and history of depression compared to those who did not receive intravenous iron therapy. Unadjusted analysis showed women who received intravenous iron had higher incidence of PND (18.5%) than those who did not (13.4%) (p = 0.008). Multivariable analysis showed no significant association between intravenous iron and PND incidence (aOR 1.21, 95%CI 0.89-1.63, p = 0.232), although history of depression (aOR 2.42, 95%CI 1.91-3.08, p < 0.001), higher gravidity (aOR 1.09, 95%CI 1.02-1.17, p = 0.016), and Medicaid insurance (aOR 1.44, 95%CI 1.16-1.80, p = 0.001) were independently associated with PND.

CONCLUSION

Intravenous iron for antenatal anemia was not associated with significant change in the incidence of PND.

Iron, neuro‐bioavailability and depression

Medical management of iron deficiency (ID) requires to consider its consequences in biochemical and physiological plural functions, beyond heme/hemoglobin disrupted synthesis. Fatigue, muscle weakness, reduced exercise capacity, changes in thymia and modified emotional behaviors are the commonest symptoms integrated in the history of ID, dependent or not of the hemoglobin concentration. The relationship between depression and absolute ID (AID) is a condition which is often unrecognized. Neuro‐bioavailability and brain capture of blood iron are necessary for an appropriate synthesis of neurotransmitters (serotonin, dopamine, noradrenaline). These neurotransmitters, involved in emotional behaviors, depend on neuron aromatic hydoxylases functioning with iron as essential cofactor. Noradrenaline also has impact on neuroplasticity via brain‐derived neurotrophic factor (BDNF), which is key for prefrontal and hippocampus neurons playing a role in depression. Establishing the formal relationship between depression and AID remains difficult. Intracerebral reduced iron is still hard to quantify by neuroimaging and single‐photon emission computed tomography (SPECT) now tends to explore the neurotransmission pathways. AID has to be looked for and identified in the context of depression, major episode or resistant to conventional treatment such as serotonin reuptake inhibitor, and even in the absence of anemia, microcytosis or hypochromia (non‐anemic ID). Confronted to brain imaging, blood iron status evaluation is indicated, especially in depressed, treatment‐resistant, iron‐deficient young women. In patients suffering from depression, increase in the prevalence of AID should be considered, in order to deliver a suitable treatment, considering both anti‐depressive program and iron supplementation if AID.

Characterisation of anaemia amongst school going adolescent girls in rural Haryana, India

OBJECTIVE

High burden of anaemia exists amongst rural adolescent girls in India. The objective of this study was to characterise anaemia in school going adolescent girls in rural Haryana, India.

DESIGN

Linear and multiple logistic regression analysis of data collected prior to an intervention trial was conducted. Participants were classified into anaemic (haemoglobin <12 g/dl) and non-anaemic group and were further classified into deficiencies of Fe, folate or vitamin B12, mixed, anaemia of other causes and inflammation.

SETTING

Three schools in Ballabgarh block of Faridabad District, Haryana, India.

PARTICIPANTS

One hundered and ninety-eight non-anaemic and 202 anaemic adolescent girls (12-19 years).

RESULTS

Anaemic girls had 29·6 % Fe deficiency, 28·1 % folate or vitamin B12 deficiency, 15·8 % mixed deficiency and 9·7 % acute inflammation. Anaemia of other causes was found in 16·8 % of the anaemic participants. Girls with Fe and isolated folate deficiency had 2·5 times and four times higher odds of developing anaemia, respectively, as compared with non-anaemic girls. Fe deficiency with no anaemia was found amongst 11 % non-anaemic girls. Non-anaemic girls had a high prevalence of combined deficiency of folate or vitamin B12 (29·5 %) and acute inflammation (14·4 %).

CONCLUSIONS

The current strategy of Fe and folic acid supplementation alone will not suffice for achieving the desired reduction in the prevalence of anaemia as unknown causes and anaemia of inflammation contribute to a substantial proportion of anaemia. Integrating other nutrition-specific components like improving water, sanitation and hygiene practices with the ongoing micronutrient supplementation program will comprehensively tackle anaemia. Unknown causes of anaemia warrant further research.

Liposomal ferric pyrophosphate and ascorbic acid supplementation in pregnant women with iron deficiency anaemia: haematochemical, obstetric, neonatal and psychological outcomes in a prospective observational study

This study aimed to determine the effects of liposomal iron pyrophosphate/ascorbic acid on clinical and psychological outcomes in pregnant women. Women at the 11th-13th weeks of gestation with iron deficiency anaemia assuming Sideremil™ from April 2018 to May 2019 were recruited. Haematochemical, obstetric, neonatal and psychological outcomes were investigated at the enrolment, 21-23 weeks of gestation, 30-32 weeks of gestation and after 6 weeks from childbirth. Results showed significant positive effects on haemoglobin, ferritin, sideremia and transferrin levels, compared to baseline data. A significant improvement of anxiety and depression levels was also observed. Regarding the quality of life, all the domains significantly improved, especially the Physical Role domain. Our results indicate that Sideremil^™ may be a valid treatment for iron deficiency anaemia in pregnant women, since it significantly improves haematological and mental health outcomes. However, further studies are needed to confirm these results.

Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean

The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

The effectiveness of iron supplementation for postpartum depression: A protocol for systematic review and meta-analysis

BACKGROUND

Postpartum depression (PPD) is one of the most common postpartum psychiatric disorders. The prevalence of PPD ranges from approximately 10% to 30%. In recent years, iron supplementation has emerged as potential means to treat PPD, and an increasing number of studies have been published to support the effectiveness of iron supplementation for PPD. we will conduct a comprehensive systematic review and meta-analysis to evaluate the evidence of randomized controlled trials for iron supplementation treatment of PPD.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, China Science, and Technology Journal Database, and Chinese Biomedical Literature Database will be searched from their inception of databases to December 31, 2020. Two reviewers will select articles, extract data and assess the risk of bias independently. Any disagreement will be resolved by discussion with the third reviewer. Review Manager 5.3 software will be used for data synthesis. The Cochrane risk of bias assessment tool will be used to assess the risk of bias.

RESULTS

This study will conduct a comprehensive literature search and provide a systematic synthesis of current published data to explore the effectiveness of iron supplementation for PPD.

CONCLUSIONS

This systematic review and meta-analysis will provide clinical evidence for the effectiveness of iron supplementation for PPD, inform our understanding of the value of iron supplementation in improving PPD symptoms, and help clinicians to make better decisions regarding the appropriate role of iron supplementation as a part of prevention and treatment routines.

STUDY REGISTRATION NUMBER

INPLASY2020110007.

Iron deficiency, depression, and fatigue in inflammatory bowel diseases

Background Iron deficiency and anemia are common findings in IBD. Treatment of anemia improves quality of life. Neurological symptoms like depression or anxiety are also common in IBD; however, their relationship with ID has not been studied in detail.

Methods Prospective, single center, non-interventional trial in an IBD cohort (n = 98), which is generally at risk for ID. Quality of sleep (using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Insomnia Severity Index) and the presence of fatigue (Piper fatigue scale), depression (Self-rating Depression Scale [SDS]) or anxiety (Self-rating Anxiety Scale [SAS]) were related to ID (ferritin, transferrin saturation), anemia (hemoglobin), and inflammatory disease activity (CRP).

Results ID was present in 35 %, anemia in 16 %, and inflammation in 30 %. The overall quality of sleep in this cohort was similar to that reported for the general population. ID, anemia, or inflammation had no influence on the PSQI (median 4.0 [CI 3.0–5.0]), the ESS 5.5 (5.0–7.0), and the ISI 4.00 (2.5–5.5). Fatigue (PFS; present in 30 %), anxiety (SAS; present in 24 %), and depression (SDS; present in 33 %) were more common than in the general population. Iron deficient and anemic patients were more likely to be depressed (p = 0.02 and p < 0.01) and showed a trend towards presence of fatigue (p = 0.06 and 0.07). Systemic inflammation as measured by CRP had no effect on any of these conditions.

Conclusion In this IBD cohort, ID and anemia affect depression and possibly fatigue independent of the presence of inflammation.

The effects of intravenous iron supplementation on fatigue and general health in non-anemic blood donors with iron deficiency: a randomized placebo-controlled superiority trial

We investigated whether intravenous iron supplementation improves fatigue and general health in non-anemic repeat adult blood donors with iron deficiency (ferritin ≤ 50 µg/L). Of 1,487 potentially eligible participants, 203 were randomly assigned to a single intravenous dose of 800 mg iron-carboxymaltose and 202 to placebo; 393 participants completed the trial. At 6 to 8 weeks after intervention, self-rated mean fatigue scores (numeric rating scale from 1-10, primary outcome) were 3.9 ± 1.8 in the iron supplementation group and 4.0 ± 2.2 in the placebo group, showing no group difference (p = 0.819). Pre-specified subgroup analyses of gender, ferritin < 25 µg/L and fatigue ≥ 4 points, as well as exploratory analyses of lower ferritin cut-offs did not reveal any between-group differences. In terms of secondary outcomes, the mean differences were 114.2 µg/L for ferritin (95% CI 103.1-125.3) and 5.7 g/L for hemoglobin (95% CI 4.3-7.2) with significantly higher values in the iron supplementation group. No group differences were observed for different measures of general well-being and other clinical and safety outcomes. Intravenous iron supplementation compared with placebo resulted in increase of ferritin and hemoglobin levels in repeat blood donors with low iron stores, yet had no effect on fatigue and general well-being.

The contribution of iron deficiency to the risk of peripartum transfusion: a retrospective case control study

Background

Iron deficiency in pregnancy is associated with inferior maternal and fetal outcomes. Postpartum depression, prematurity, intrauterine growth restriction, impaired childhood cognition and transfusion are all sequelae of maternal iron deficiency anemia. Transfusion to women of childbearing age has important consequences including increasing the risk of hemolytic disease of the fetus and newborn with future pregnancies. The relative contribution of iron deficiency to transfusion rates in the peripartum period is unknown. This study aimed to identify the prevalence of iron deficiency and anemia in pregnant women that received peripartum transfusions relative to age-matched non-transfused controls.

Methods

We performed a retrospective case-control study of all women that were transfused in the peripartum period from January, 2014 to July, 2018. Cases were compared to the next age matched control to deliver at our institution. The primary objective was to determine the proportion of patients with iron deficiency in pregnancy or anemia in pregnancy in cases and controls. Charts were reviewed for predisposing risk factors for iron deficiency, laboratory measures of iron deficiency and anemia, iron supplementation history and maternal and fetal outcomes. Factors associated with peripartum transfusion were analyzed using a multivariate logistic regression.

Results

169 of 18, 294 (0.9%) women were transfused in the peripartum period and 64 (44%) of those transfused received 1 unit. Iron deficiency or anemia were present in 103 (71%) transfused women and 74 (51%) control women in pregnancy (OR 2.34, 95% CI: 3.7–18.0). Multivariate analysis identified social work involvement (adjusted OR 4.1, 95% CI: 1.8–10.1), intravenous iron supplementation in pregnancy (adjusted OR 3.8, 95% CI: 1.2–17.4) and delivery by unscheduled cesarean section (adjusted OR 2.8, 95% CI: 1.3–6.2) as significant predictors of peripartum transfusion.

Conclusions

Pregnant women being followed by a social worker, receiving intravenous iron supplementation in pregnancy or who deliver by unscheduled cesarean section are more likely to receive a red blood cell transfusion. Women with iron deficiency or anemia in pregnancy are at increased risk of peripartum blood transfusions and warrant early and rigorous iron supplementation.

The association between banana consumption and the depressive symptoms in Chinese general adult population: A cross-sectional study

BACKGROUND

Banana contains many kinds of substances that are beneficial to depressive symptoms. However, there are no epidemiological researches directly to explore the association between banana consumption and depressive symptoms. This study aimed to investigate whether the banana consumption is related to depressive symptoms in a general adult population.

METHODS

A cross-sectional study was performed in 24,673 adults in Tianjin. Banana consumption was evaluated via a validated food frequency questionnaire. Depressive symptoms were assessed by using Self-Rating Depression Scale (SDS). The association between banana consumption and depressive symptoms was analyzed by multiple logistic regression analysis.

RESULTS

The prevalence of depressive symptoms was 16.1% in males and 18.4% in females (SDS ≥ 45), respectively. In males, comparing to the reference group (almost never), the multivariable adjusted odds ratios (ORs) (95% confidence intervals) of depressive symptoms across banana consumption were 0.86 (0.74, 0.99) for <1 time/week, 0.76 (0.66, 0.88) for 1-3 times/week and 0.97 (0.82, 1.16) for ≥4 times/week. By contrast, the multivariable adjusted ORs (95% confidence intervals) were 1.11 (0.94, 1.32) for <1 time/week, 0.99 (0.85, 1.16) for 1-3 times/week and 1.22 (1.02, 1.46) for ≥4 times/week in females. Similar association was observed when other cut-offs (SDS ≥ 48 and 50) were used to define depressive symptoms.

LIMITATION

This is a cross-sectional study, causality remains unknown.

CONCLUSION

Findings from this study suggested a negative association between moderate banana consumption and depressive symptoms in males. In females, high banana consumption is positively related to depressive symptoms.

Association between anemia and maternal depression: A systematic review and meta-analysis

Previous observational epidemiological studies have reported inconsistent findings regarding the association between anemia and the risk of maternal depression. In the present study, we investigated the relationship between anemia and the risk of maternal depression using a meta-analysis. We searched PubMed, EMBASE, and the bibliographies of relevant articles in May 2019. Three evaluators independently reviewed and selected the eligible studies based on the predetermined selection criteria. A random-effects model was employed to calculate meta-estimates of the association between anemia and maternal depression. Of the 1305 articles, 15 observational epidemiological studies (five case-control studies and 10 cohort studies) were included in the final analysis. A total of 32,792,378 women were included. Anemia was significantly associated with an increased risk of maternal depression in the random-effects meta-analysis of 15 studies (OR/RR: 1.53, 95% CI: 1.32-1.78). The association was consistent in both antepartum (OR/RR: 1.36, 95% CI: 1.07-1.72) and postpartum depression (OR/RR: 1.53, 95% CI: 1.32-1.78). Subgroup meta-analyses based on definition of anemia, definition of depression, and methodological quality reported consistent findings. The current meta-analysis showed that anemia was associated with an increased risk of maternal depression.

Anaemia and depletion of iron stores as risk factors for postpartum depression: a literature review

PURPOSE

Iron-deficiency and anaemia are common in pregnant and postpartum women because of increasing iron demand and blood loss. Many women also enter pregnancy with pre-depleted iron stores. We reviewed the evidence linking anaemia and/or iron-deficiency to postpartum depression (PPD).

METHODS

We identified seventeen studies in four databases including randomized-controlled trials (RCTs) and observational studies assessing the impact of anaemia, iron-deficiency and iron supplementation on the risk of PPD. We extracted data on sample size, geographical region, obstetrical complications, measures of depression, haemoglobin, iron levels and intake of iron supplementation and critically appraised the results from the studies.

RESULTS

Eight out of ten studies found higher risk for PPD (r - 0.19 to -0.43 and ORs 1.70-4.64) in anaemic women. Low ferritin in the postpartum period but not during pregnancy was associated with increased risk of PPD. Iron supplementation in the postpartum period decreased risk of PPD in four out of five studies, whereas it did not protect from PPD if given during pregnancy. Limitations include study heterogeneity, discrepancy of prevalence of PPD and usage of a screening tool for evaluation of PPD.

CONCLUSION

Anaemia and/or iron-deficiency may contribute to PPD in at-risk women. Further studies should elucidate the association between these entities.

Intravenous iron isomaltoside treatment of women suffering from severe fatigue after postpartum hemorrhage

Background and objectives: To explore if intravenous iron isomaltoside (Monofer^®) leads to a better relief of fatigue than current treatment practice with oral iron in women suffering from severe fatigue after postpartum hemorrhage. Materials and methods: This is a subanalysis of a single-center, open-label, randomized controlled trial conducted in women suffering from postpartum hemorrhage. Participants were randomized 1:1 to 1200 mg iron isomaltoside or current treatment practice with oral iron. We measured fatigue by the Multidimensional Fatigue Inventory (MFI) and Edinburgh Postnatal Depression Scale, and determined hematological parameters. The subanalysis includes all participants with a high fatigue score (MFI physical fatigue score >15) at inclusion. The primary endpoint was aggregated change in physical fatigue score from inclusion to 12 weeks postpartum with a predefined minimum clinically relevant difference of 1.8. The trial is registered at ClinicalTrials.gov (identifier: NCT01895218). Results: A total of 85 women had a high fatigue score at inclusion. The aggregated change in physical fatigue score was -2.3 (confidence interval 95%: -3.3; -1.3) (p < .0001) in favor of iron isomaltoside. Significant differences in other fatigue and depression scores and hematological parameters were observed and all in favor of iron isomaltoside. There were no differences in side effects between the groups. Conclusions: In women suffering from severe fatigue after postpartum hemorrhage, a single dose of iron isomaltoside is associated with a statistically significant and clinically relevant reduction in aggregated physical fatigue within 12 weeks after delivery, when compared to current treatment practice with oral iron and with a similar safety profile.

Iron Deficiency and Risk of Maternal Depression in Pregnancy: An Observational Study

OBJECTIVE

Maternal depression during pregnancy can affect both the mother and her family. Although research has suggested that iron deficiency is associated with depression in the general population, this link has not been examined during the antenatal period. Our objective was to determine whether iron deficiency is associated with maternal depression during middle to late pregnancy.

METHODS

A retrospective study was conducted using the medical records of patients seen at the Women's Health Concerns Clinic at St. Joseph's Healthcare Hamilton in Hamilton, Ontario between 2009 and 2016. Women with serum ferritin data during middle to late pregnancy (>20 weeks' gestation) (N = 142) were categorized as either iron deficient (ferritin <12 µg/L) or iron sufficient. Edinburgh Postnatal Depression Scale (EPDS) scores and the odds of developing antenatal depression (EPDS ≥12) between the two groups were compared.

RESULTS

Iron deficient pregnant women scored significantly higher on the EPDS (10.14 ± 5.69 vs. 7.87 ± 5.75; P = 0.03) and were more likely to develop antenatal depression (45% vs. 25%; P = 0.02) compared with women who were not. The odds of developing antenatal depression were two and one half times higher among iron deficient women (adjusted OR 2.51; 95% CI 1.14-5.52).

CONCLUSION

These findings suggest that iron deficiency is associated with higher levels of depression during pregnancy. Although these results require replication, iron deficiency may be an important risk factor for maternal depression during pregnancy.

Anemia, Depression, and Suicidal Attempts in Women: Is There a Relationship?

Objective:

Suicide is a social health problem worldwide. Anemia has been associated with depression. Since it remains debated whether anemia is associated with suicide independently of depression, we evaluate this probable association in women who attempted suicide through acute poisoning.

Methods:

The study design was cross-sectional and performed on women who attempted suicide through intentional poisoning with age more than 18 years old. Different variables were evaluated and compared in patients with respect to anemia, depression, other psychiatric diseases and history of suicide. Independent t-tests and binary logistic regression were used for statistical analysis.

Findings:

Nearly 26.2% of the women had anemia (n = 55). Most women with anemia were in the age group of 20–40 years (68.8%). 52.2% of the women were married. Mixed-drug poisoning was the most common (60.1%) followed by pesticide (8.9%), and antipsychiatric medications (8.4%). There was a significant difference in duration of hospitalization between anemic and nonanemic patients. Nearly 72.7% of the patients survived without complications. Anemia and depression were not significant predictive factors for depression and suicide. However, in our patients, the presence of other underlaying psychiatric disorders was a risk factor for suicidal attempt through acute poisoning.

Conclusion:

In women who attempted suicide through acute poisoning, anemia and depression were not predicting factors for suicide. However, the presence of other underlying psychiatric psychiatric disorders had a predictive value for the outcome of treatment. Length of hospital stay was also correlated with anemia.

Psychiatric comorbidities in movement disorders

Psychiatric comorbidities are common in movement disorders. This review provides a practical approach to help clinicians to recognize psychiatric disorders in the most frequent movement disorders. However, the extent of neurodegeneration, as well as the impact of medications with considerable CNS effects, influences the diverse psychiatric presentations that, in turn, are influenced by the stress of living with a movement disorder. Depression, anxiety, and psychosis are the most common psychiatric comorbidities in movement disorders and of the medications used to treat the motor disturbances. These psychiatric problems impair patients' functioning throughout the course of the chronic neurodegenerative diseases. Due to the direct connection between brain dysfunction and psychiatric symptoms, there is hope that understanding the psychiatric comorbidities in movement disorders will lead to a better quality-of-life.

Quantitative Susceptibility Mapping Reveals an Association between Brain Iron Load and Depression Severity

Previous studies have detected abnormal serum ferritin levels in patients with depression; however, the results have been inconsistent. This study used quantitative susceptibility mapping (QSM) for the first time to examine brain iron concentration in depressed patients and evaluated whether it is related to severity. We included three groups of age- and gender-matched participants: 30 patients with mild-moderate depression (MD), 14 patients with major depression disorder (MDD) and 20 control subjects. All participants underwent MR scans with a 3D gradient-echo sequence reconstructing for QSM and performed the 17-item Hamilton Depression Rating Scale (HDRS) test. In MDD, the susceptibility value in the bilateral putamen was significantly increased compared with MD or control subjects. In addition, a significant difference was also observed in the left thalamus in MDD patients compared with controls. However, the susceptibility values did not differ between MD patients and controls. The susceptibility values positively correlated with the severity of depression as indicated by the HDRS scores. Our results provide evidence that brain iron deposition may be associated with depression and may even be a biomarker for investigating the pathophysiological mechanism of depression.

Recent advances in understanding maternal perinatal mood disorders

The study of perinatal mental health (mental health during pregnancy and postpartum) is a complex field of study that is of major importance both for the mental and physical health of new mothers and for the neurobehavioral development and long-term functioning of the children they bear. In this review, we cover the most recent additions to this rapidly evolving field. Notable advances include further illumination of the epidemiological patterns and clinical manifestations of perinatal mood disruption; new efficacy data on treatment and prevention; clarifications of the respective contributions of maternal mental illness and psychotropic medication to outcomes of pregnancy, birth, and child development; and updated expert guidelines for screening.

Site-Specific Onset of Low Bone Density and Correlation of Bone Turnover Markers in Exclusive Breastfeeding Mothers

PURPOSE

Lactation often affects calcium metabolism and induces bone loss. Calcium supplementation and a high calcium diet are recommended to prevent bone loss, especially during inadequate calcium intake. Our study aimed at determining bone loss in breastfeeding mothers, and if it occurred, whether it was site specific and there were correlations between serum bone turnover markers.

MATERIALS AND METHODS

Since the 6-month exclusive breastfeeding is usually recommended in several countries, our study examined bone mineral density (BMD) in early (1-2 month), mid (3-4 month)-, and late (5-6 month) lactation compared with nonpregnant, nonlactating control women. Site-specific bone loss was monitored in lumbar vertebrae and femora. Bone turnover markers, that is, C-terminal telopeptide of type 1 collagen and N-terminal propeptide of type 1 collagen (P1NP), were determined by electrochemiluminescence immunoassays.

RESULTS

The onset of bone loss in exclusive breastfeeding mothers was site specific, for example, in the lumbar bone at mid-lactation and in the femoral bone in late lactation. Serum ionized calcium levels in late lactation were lower than the normal levels. In addition, a correlation was found between bone turnover marker, P1NP, and femoral BMD.

CONCLUSIONS

The onset of bone loss in exclusive breastfeeding mothers was site specific, and the lumbar bone was a vulnerable and perhaps better representative site for bone loss detection. It was suggested that the optimal starting time for calcium supplementation should be before the mid-lactation when the bone loss was observed. In addition, the biochemical marker that best predicted the onset of bone loss in lactating women was P1NP.