The obsessive-compulsive spectrum in the perinatal period: a prospective pilot study

Obsessive-compulsive and related disorder symptoms in the perinatal period: prevalence and associations with postpartum functioning

Obsessive-compulsive disorder (OCD) symptoms are more likely to develop or be exacerbated during pregnancy and the postpartum period, which can cause significant distress and impairment. However, the disorders grouped with OCD in the DSM-5, obsessive-compulsive and related disorders (OCRD; e.g., hoarding disorder (HD), body dysmorphic disorder (BDD), trichotillomania (TTM), excoriation disorder (ED)), have rarely been examined in the perinatal period. This study aimed to explore (1) the prevalence of all clinically significant OCRD symptoms in pregnancy and the postpartum period and (2) the correlations between OCRD psychopathology and postpartum functioning. Participants were recruited during their second trimester of pregnancy from a Midwestern medical center. Participants completed an online questionnaire and a semi-structured clinical interview during pregnancy (28-32 weeks' gestation, N = 276) and the postpartum period (6-8 weeks, N = 221). BDD and OCD symptoms were the most prevalent. In pregnancy, 14.9% (N = 41) of participants endorsed clinically significant BDD symptoms and 6.2% (N = 17) endorsed clinically significant OCD symptoms. In the postpartum period, 11.8% (N = 26) endorsed clinically significant BDD symptoms and 14% (N = 31) endorsed clinically significant OCD symptoms. Poorer postpartum functioning was associated with elevated OCRD symptoms in pregnancy and postpartum. OCRD symptoms occur during pregnancy and the postpartum period at rates similar or higher than other life periods. Elevated OCRD symptoms are associated with poorer postpartum functioning across domains. Future research should explore how all OCRD symptoms may affect functioning in the perinatal period, not only OCD symptoms.

Perinatal Obsessive-Compulsive Disorder: Epidemiology, Phenomenology, Etiology, and Treatment

PURPOSE OF REVIEW

We review recent evidence concerning the epidemiology, etiology, and treatment of obsessive-compulsive disorder (OCD) in the perinatal period. We examine studies reporting on rates of both new-onset OCD and exacerbation in both pregnancy and postpartum; explore both biological and psychosocial risk factors for the disorder; and review the latest evidence concerning treatment.

RECENT FINDINGS

Evidence is limited in all areas, with rates of both OCD and subthreshold obsessive-compulsive symptoms varying widely across studies. Prevalence is likely higher in the perinatal period than in the general population. Clinical features in the perinatal period are more likely than at other times to concern harm to the child, with contamination and aggressive obsessions and cleaning and checking compulsions especially common. Research into the biological etiology is too limited at this time to be definitive. Both observational and randomized controlled trials support cognitive behavioral therapy with exposure and response prevention (CBT with ERP) as a first-line treatment, with limited evidence also supporting the use of selective serotonin reuptake inhibitors (SSRIs). Treatment considerations in the perinatal period must weigh the risks of treatment vs. the risks of untreated illness. Perinatal OCD is common and can be impairing. Clinical features differ somewhat compared to non-perinatal periods. Treatment does not differ from that used in the general population, though evidence pertaining specifically to the perinatal period is sparse.

Maternal Obsessive-Compulsive Symptoms and Infant Feeding Practices

Purpose: The purpose of this study was to examine associations between postpartum obsessive-compulsive (OC) symptoms, infant care and feeding worries, and breastfeeding experiences in a sample of postpartum women. Materials and Methods: Women were recruited via an online U.S. research volunteer database and were eligible if they were aged 18-47 years, their primary language was English, they had an infant 2-6 months old, and tried breastfeeding the infant at least once. Participants completed a survey to assess breastfeeding experiences and practices, OC symptoms and other mental health conditions, and demographics. Modified Poisson regression and linear regression were used to estimate associations between clinically elevated OC symptoms, reported thoughts or worries about infant feeding and care, and breastfeeding experiences, problems, and duration. Results: Of 232 participants, 32 (14%) had clinically elevated OC symptoms. These women had more perinatal OC symptoms (scoring 3.6 points higher on perinatal OC symptoms score [95% confidence interval {CI}: 0.4 to 6.9]), including symptoms specific to infant care and feeding [e.g., adjusted relative risk_{(repeated washing of baby's bottles, bowl, or plate)} = 2.37, 95% CI:1.55 to 3.64], and more breastfeeding problems (adjusted β = 0.3, 95% CI: 0.0 to 0.2) than women with fewer OC symptoms. However, they did not report an overall worse breastfeeding experience (adjusted β = 0.4, 95% CI: -9.3 to 10.1). Adjusted models controlled for depressive symptoms. Conclusions: Obsessive thoughts and compulsions were common in this sample and extended to infant feeding activities. These symptoms were associated with more breastfeeding problems. Interactions in mother-infant dyads are critical because of lasting impacts on parent-child relationships and child development. Treating OC symptoms may foster healthier mother-infant relationships.

The Relationship between Pregnancy-related Anxiety and Maternal-fetal Attachment among Primigravida

BACKGROUND: Many studies support the hypothesis that pregnancy-related anxiety (PRA) is strongly linked to postpartum depression, preterm births, low birth weight, fetal growth restriction, pregnancy complications, and negative infant outcomes. PRA has also been associated with mother-fetal bond during pregnancy that a special relationship between the mother and infant and growth beyond before the infant is born. Although extensive studies on PRA and maternal-fetal attachment (MFA) have been carried out, little attention on these issues is done in the Indonesian context. AIM: To fill such a gap, the present study aimed to investigate the relationship between maternal PRA and MFA. METHODS: Expectant mothers who visit their antenatal care in the primary health community services at Yogyakarta participated in this study. They were recruited using a purposive sampling technique based on the criteria: (a) The 1st time pregnancy, (b) in the late stage of pregnancy, (c) have no complication, (d) mother at any age range, and (e) mother at any education level. G-power 3.1.9.2 with effect size 0.15 has used to determine the number of samples, 84 people. Statistical analysis Pearson correlation has been applied and calculates the t relationship between two variables. General linier model analysis conducted the contribution of demographic variables to PRA and MFA. RESULTS: There is a significant relationship between maternal anxiety during pregnancy and MFA (p < 0.001) and a significant correlation between PRA and maternal age. However, there were no correlation between MFA and demographic variables. IMPLICATION FOR PRACTICE: Findings study provides the crucial information as the new approach to enhance the quality of care of mother’s and infant’s health during pregnancy as well as to promote maternal mental health.

Fathers' Experience of Perinatal Obsessive-Compulsive Symptoms: A Systematic Literature Review

Perinatal Obsessive-Compulsive Disorder (pOCD) refers to the onset/exacerbation of Obsessive-Compulsive Disorder (OCD) during the perinatal period. This disorder has been studied in mothers, with limited research conducted on fathers. The aim of the current study was to conduct the first systematic review of research investigating the experience of pOCD in fathers. A systematic review was conducted via electronic searches of Scopus, ProQuest, APA PsychNet, PubMed, and EBSCOhost. There were 523 articles identified and screened for eligibility, resulting in six eligible studies included in the final review. All studies reported the presence of subclinical obsessive-compulsive symptoms in fathers during the perinatal period, with the prevalence comparable to mothers. Compared to mothers, however, fathers were found to report less intrusion-related distress. Two studies reported a correlation between dysfunctional beliefs, negative appraisal of intrusions, and pOCD symptoms. Common categories of obsessive thoughts and compulsions experienced by fathers were also identified. Fathers appear susceptible to pOCD, which is consistent with the Cognitive-Behavioral Theory of OCD. Future research is recommended, therefore, to investigate clinical prevalence and severity of pOCD in fathers, particularly relative to mothers, and further investigate the role of dysfunctional beliefs in the development of pOCD.

Peripartum complications associated with obsessive compulsive disorder exacerbation during pregnancy

Prior research has shown that onset or exacerbation of OCD is associated with menstruation, pregnancy, and the post-partum period. However, the underlying cause is unclear. The goal of this study was to assess whether pregnancy and birth complications were associated with OCD symptoms exacerbation, among women with established OCD. Two-hundred and five (n=205) women with OCD retrospectively reported information on their physical and mental health during their first pregnancy. Over a third of the sample (34%) reported an exacerbation in their OCD symptoms. History of pregnancy and birth complications in the first pregnancy were similar between women who did and did not experience symptom exacerbation, with the exception of gestational diabetes, which was significantly more common among women who experienced exacerbation (7% vs 1%, p=0.03). In a multivariable logistic regression model, gestational diabetes remained significantly associated with exacerbation of OCD symptoms (OR=8.44 [95% CI 1.37-77.27]; p=0.03), even after adjusting for maternal age, OCD severity and treatment, premenstrual OCD symptom increase, stress during pregnancy, and major depression or anxiety disorder diagnosis during pregnancy. We discuss potential explanations for this link. These findings should be treated as hypothesis-generating and need to be replicated in a larger, prospective study.

Health practitioners' recognition and management of postpartum obsessive-compulsive thoughts of infant harm

The postpartum period has been associated with elevated rates of onset of obsessive-compulsive disorder (OCD) among women, with a prevalence of 2-9%. Postpartum OCD is often characterized by recurrent, unwanted, and highly distressing thoughts, images, or impulses of deliberate infant harm. This study investigated health practitioners' recognition of, and clinical management strategies for, postpartum obsessive-compulsive symptoms (OCS). Ninety-four perinatal health practitioners from a range of disciplines and professional backgrounds completed a survey comprised of a hypothetical case vignette and questions eliciting their responses to a clinical presentation of postpartum infant harming obsessions. Almost 70% of participants did not accurately identify OCS within the case. Furthermore, the majority of practitioners endorsed at least one contraindicated clinical management strategy likely to aggravate postpartum OCS. Accurate recognition of OCS was associated with the selection of fewer contraindicated strategies. Some aspects of practitioner training and experience were associated with correct OCS identification. These findings underscore the need for targeted, interdisciplinary education to improve the detection and management of women experiencing postpartum OCS.

The Psychopharmacology of Obsessive-Compulsive Disorder: A Preclinical Roadmap

This review evaluates current knowledge about obsessive-compulsive disorder (OCD), with the goal of providing a roadmap for future directions in research on the psychopharmacology of the disorder. It first addresses issues in the description and diagnosis of OCD, including the structure, measurement, and appropriate description of the disorder and issues of differential diagnosis. Current pharmacotherapies for OCD are then reviewed, including monotherapy with serotonin reuptake inhibitors and augmentation with antipsychotic medication and with psychologic treatment. Neuromodulatory therapies for OCD are also described, including psychosurgery, deep brain stimulation, and noninvasive brain stimulation. Psychotherapies for OCD are then reviewed, focusing on behavior therapy, including exposure and response prevention and cognitive therapy, and the efficacy of these interventions is discussed, touching on issues such as the timing of sessions, the adjunctive role of pharmacotherapy, and the underlying mechanisms. Next, current research on the neurobiology of OCD is examined, including work probing the role of various neurotransmitters and other endogenous processes and etiology as clues to the neurobiological fault that may underlie OCD. A new perspective on preclinical research is advanced, using the Research Domain Criteria to propose an adaptationist viewpoint that regards OCD as the dysfunction of a normal motivational system. A systems-design approach introduces the security motivation system (SMS) theory of OCD as a framework for research. Finally, a new perspective on psychopharmacological research for OCD is advanced, exploring three approaches: boosting infrastructure facilities of the brain, facilitating psychotherapeutic relearning, and targeting specific pathways of the SMS network to fix deficient SMS shut-down processes. SIGNIFICANCE STATEMENT: A significant proportion of patients with obsessive-compulsive disorder (OCD) do not achieve remission with current treatments, indicating the need for innovations in psychopharmacology for the disorder. OCD may be conceptualized as the dysfunction of a normal, special motivation system that evolved to manage the prospect of potential danger. This perspective, together with a wide-ranging review of the literature, suggests novel directions for psychopharmacological research, including boosting support systems of the brain, facilitating relearning that occurs in psychotherapy, and targeting specific pathways in the brain that provide deficient stopping processes in OCD.

Neurobiology of maternal mental illness

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

Prevalence, onset and course of anxiety disorders during pregnancy: A systematic review and meta analysis

BACKGROUND

Anxiety disorders during pregnancy are associated with various adverse outcomes. Previous reviews of anxiety disorders during pregnancy have methodological limitations and were conducted without a meta-analysis. The present study is a systematic review and meta-analysis of the published research on the prevalence, onset and course of all anxiety disorders during pregnancy plus obsessive-compulsive disorder (OCD) and posttraumatic stress disorder.

METHODS

A comprehensive literature search was performed on a wide range of databases. A random effects model was used for the meta-analysis.

RESULTS

Thirty-six studies were included. Prevalence rates of anxiety disorders during pregnancy varied considerably. The pooled prevalence rate of each disorder during pregnancy was 3%, except for specific phobia, where it was 6%. Between 13% and 39% of pregnant OCD women had the onset of OCD during pregnancy, and this occurred mainly in the 2nd trimester. The onset of panic disorder (PD) was more common in the 1st and 2nd trimesters of pregnancy.

LIMITATIONS

Different designs of the included studies, as well as different assessment tools and assessment times during pregnancy and the paucity of studies of the onset and course, preclude definitive conclusions.

CONCLUSIONS

Anxiety disorders are common during pregnancy. Unlike prevalence rates of other anxiety disorders during pregnancy, prevalence rates of PD and OCD during pregnancy were higher than their lifetime prevalence rates in women in the general population. The onset of OCD during pregnancy is not rare and the course of PD and OCD during pregnancy is highly variable. These findings suggest that pregnancy may be a specific risk factor for the occurrence and/or exacerbation of PD and OCD and underscore the importance of their early diagnosis and management.

The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis

OBJECTIVE

To estimate the prevalence of anxiety disorders in pregnant and postpartum women and identify predictors accounting for variability across estimates.

DATA SOURCES

An electronic search of PsycINFO and PubMed was conducted from inception until July 2016, without date or language restrictions, and supplemented by articles referenced in the obtained sources. A Boolean search phrase utilized a combination of keywords related to pregnancy, postpartum, prevalence, and specific anxiety disorders.

STUDY SELECTION

Articles reporting the prevalence of 1 or more of 8 common anxiety disorders in pregnant or postpartum women were included. A total of 2,613 records were retrieved, with 26 studies ultimately included.

DATA EXTRACTION

Anxiety disorder prevalence and potential predictor variables (eg, parity) were extracted from each study. A Bayesian multivariate modeling approach estimated the prevalence and between-study heterogeneity of each disorder and the prevalence of having 1 or more anxiety disorder.

RESULTS

Individual disorder prevalence estimates ranged from 1.1% for posttraumatic stress disorder to 4.8% for specific phobia, with the prevalence of having at least 1 or more anxiety disorder estimated to be 20.7% (95% highest density interval [16.7% to 25.4%]). Substantial between-study heterogeneity was observed, suggesting that "true" prevalence varies broadly across samples. There was evidence of a small (3.1%) tendency for pregnant women to be more susceptible to anxiety disorders than postpartum women.

CONCLUSIONS

Peripartum anxiety disorders are more prevalent than previously thought, with 1 in 5 women in a typical sample meeting diagnostic criteria for at least 1 disorder. These findings highlight the need for anxiety screening, education, and referral in obstetrics and gynecology settings.

A Bayesian multivariate approach to estimating the prevalence of a superordinate category of disorders

OBJECTIVE

Epidemiological research plays an important role in public health, facilitated by the meta-analytic aggregation of epidemiological trials into a single, more powerful estimate. This form of aggregation is complicated when estimating the prevalence of a superordinate category of disorders (e.g., "any anxiety disorder," "any cardiac disorder") because epidemiological studies rarely include all of the disorders selected to define the superordinate category. In this paper, we suggest that estimating the prevalence of a superordinate category based on studies with differing operationalization of that category (in the form of different disorders measured) is both common and ill-advised. Our objective is to provide a better approach.

METHODS

We propose a multivariate method using individual disorder prevalences to produce a fully Bayesian estimate of the probability of having one or more of those disorders. We validate this approach using a recent case study and parameter recovery simulations.

RESULTS

Our approach produced less biased and more reliable estimates than other common approaches, which were at times highly biased.

CONCLUSION

Although our approach entails additional effort (e.g., contacting authors for individual participant data), the improved accuracy of the prevalence estimates obtained is significant and therefore recommended.

Treatment of severe perinatal mood disorders on a specialized perinatal psychiatry inpatient unit

Perinatal patients with bipolar and psychotic mood disorder exacerbations are challenging to treat and often receive suboptimal care. We sought to examine the treatment patterns and outcomes on one of the only US-based Perinatal Psychiatry Inpatient Units (PPIU). Perinatal patients admitted to the PPIU completed self-report measures at admission and before discharge. Retrospective chart reviews extracted history, diagnoses (current and past), and medication treatment. Patients who had discharge diagnoses of bipolar disorder, major depression with psychotic features, or postpartum psychosis were included. Forty-seven met the diagnostic inclusion criteria. Over an average length of stay (ALOS) of 9.96 days, there was significant improvement in depressive and anxiety symptoms and daily functioning (Work and Social Adjustment Scale). Psychiatric comorbidity was common. Polypharmacy was utilized in 87 %. The most common medications prescribed at discharge were antipsychotics, alone or in combination with mood stabilizers or antidepressants. ECT was performed in 10 % of cases. The complexity of patients with severe mood disorders or psychosis admitted to the PPIU supports individualized treatment plans that address both primary diagnosis and psychiatric comorbidities. Our results provide important information that can be disseminated to others to improve clinical outcomes for severe perinatal mood disorders.

Obsessive-compulsive disorder in the postpartum period: diagnosis, differential diagnosis and management

Childbirth can trigger or exacerbate a variety of psychiatric disorders but the extant literature has focused primarily on mood disorders. Obsessive-compulsive disorder (OCD) after childbirth can occur alone or in combination with other psychiatric disorders such as major depressive disorder. Due to the general lack of awareness of the relationship between childbirth and OCD among clinicians as well as patients, the disorder may be underdiagnosed or misdiagnosed as major depressive disorder. This article describes the prevalence, clinical features, common psychiatric comorbidities, differential diagnosis and potential consequences of underdiagnosis or misdiagnosis. Using case vignettes strategies for its detection and clinical management are suggested. Finally, areas in need of further research are proposed.

Obsessions and Compulsions in Postpartum Women Without Obsessive Compulsive Disorder

BACKGROUND

To describe the prevalence of obsessions and compulsions and the specific symptoms present in postpartum women without obsessive compulsive disorder (OCD).

METHODS

In this prospective cohort, women were screened with the Yale Brown Obsessive Compulsive Scale at 2 weeks postpartum. Demographics and comorbid psychiatric symptoms were compared between women with screen-positive OCD, screen-negative OCD but with some endorsed symptoms (subclinical OCD), and no OCD symptoms. The prevalence of each specific set of obsessive and compulsive symptoms and the rate of impairment from those symptoms were compared.

RESULTS

Of the 461 women included, 52 (11.2%) screened positive for OCD, while 173 (37.5%) reported experiencing subclinical obsessions or compulsions. This subclinical OCD was associated with an increased rate of depression (24%) and state-trait anxiety (8%) compared with women who did not endorse experiencing any obsessions or compulsions. Aggressive, religious, and somatic obsessions as well as obsessions with symmetry, when present, were most likely to result in OCD screen positivity.

CONCLUSIONS

Nearly half of all women who screen negative for OCD experienced obsessions or compulsions that did not result in OCD screen positivity. However, the presence of these subclinical obsessions and compulsions is associated with an increased rate of depression or anxiety.

Is postpartum depression a homogenous disorder: time of onset, severity, symptoms and hopelessness in relation to the course of depression

Background

Postpartum depression (PPD) is a common illness, but due to the underlying processes and the diversity of symptoms, some variability is exhibited. The risk of postpartum depression is great if the mother has previously suffered from depression, but there is some evidence that a certain subgroup of women only experience depression during the postpartum period.

Methods

The study group consisted of 104 mothers with postpartum major depression and a control group of 104 postpartum mothers without depression. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was used for data collection. The severity of depression and other mental symptoms were assessed using several validated rating scales.

Results

A history of past depression (82%), including depression during pregnancy (42%) and during the postpartum period (53%), was very common in those with current PPD. Eighteen per cent of mothers with current PPD had previously not had any depressive episodes and four per cent had experienced depression only during the postpartum period. Therefore, pure PPD was rare. The onset of PPD was usually (84%) within six weeks of childbirth. Obsessive-compulsive symptoms, phobic anxiety, paranoid ideation, depressed mood, diminished pleasure/interest, decreased energy, and psychomotor agitation/retardation were common with all kinds of depression histories. Pure PPD was the most similar to the first depressive episode. Nevertheless, the severity of depression, the level of hopelessness, somatisation, interpersonal sensitivity, anxiety, hostility, psychoticism, sleep disturbance, and suicidal ideation were lower, appetite changed less, and concentration was better than in other recurrent depressions.

Conclusions

According to this study, PPD is not a homogenous disorder. The time of onset, severity, symptoms, level of hopelessness, and the course of depression vary. Recurrent depression is common. All mothers must be screened during the sixth week postpartum at the latest. Screening alone is not effective; it is also important to give mothers information about PPD and to discuss the symptoms with them in order for them to recognise this disorder and possible new episodes in the future.

Obsessive-compulsive disorder and female reproductive cycle events: results from the OCD and reproduction collaborative study

BACKGROUND

Women with obsessive-compulsive disorder (OCD) often report that symptoms first appear or exacerbate during reproductive cycle events; however, little is known about these relationships. The goals of this study were to examine, in a US and a European female OCD sample, onset and exacerbation of OCD in reproductive cycle events, and to investigate the likelihood of repeat exacerbation in subsequent pregnancies and postpartum periods.

METHODS

Five hundred forty-two women (United States, n = 352; Dutch, n = 190) who met DSM-IV criteria for OCD, completed self-report questionnaires designed to assess OCD onset and symptom exacerbation associated with reproductive events.

RESULTS

OCD onset occurred within 12 months after menarche in 13.0%, during pregnancy in 5.1%, at postpartum in 4.7%, and at menopause in 3.7%. Worsening of pre-existing OCD was reported by 37.6% of women at premenstruum, 33.0% during pregnancy, 46.6% postpartum, and 32.7% at menopause. Exacerbation in first pregnancy was significantly associated with exacerbation in second pregnancy (OR = 10.82, 95% CI 4.48-26.16), as was exacerbation in first postpartum with exacerbation in second postpartum (OR = 6.86, 95% CI 3.27-14.36). Results were replicated in both samples.

CONCLUSIONS

Reproductive cycle events are periods of increased risk for onset and exacerbation of OCD in women. The present study is the first to provide significant evidence that exacerbation in or after first pregnancy is a substantial risk factor for exacerbation in or after a subsequent pregnancy. Further research is needed to identify factors related to exacerbation, so that physicians may provide appropriate recommendations to women regarding clinical issues involving OCD and reproductive cycle events.

Perinatal psychiatric disorders: an overview

Perinatal mental illness has a significant implication on maternal health, birth outcomes, and the offspring's development. Prevalence estimates of perinatal psychiatric illnesses range widely, with substantial heterogeneity in different population studies, with a lower prevalence rate in high- rather than low- or middle-income countries. Because of the potential negative impact on maternal and child outcomes and the potential lability of these disorders, the perinatal period is a critical time to identify psychiatric illnesses. Thus, obstetricians and midwives play a crucial role in assessing women's mental health needs and to refer identified women promptly for multidisciplinary specialist assessment. However, there is still limited evidence on best practice assessment and management policies during pregnancy and postpartum. This review focuses on the prevalence of common perinatal mental disorders and antenatal screening policies to identify women at risk. The effect of these conditions and their management on pregnancy, fetal outcomes, and child development are discussed.

Association between maternal mood and oxytocin response to breastfeeding

BACKGROUND

Postpartum depression is associated with reduced breastfeeding duration. We previously hypothesized that shared neuroendocrine mechanisms underlie this association. We sought to measure the association between maternal mood and neuroendocrine response to breastfeeding.

METHODS

We conducted a longitudinal cohort study of women recruited during pregnancy who intended to breastfeed. Baseline depression and anxiety history were assessed with a structured clinical interview. We measured mood symptoms using validated psychometric instruments, and we quantified affect and neuroendocrine responses to breastfeeding during laboratory visits at 2 and 8 weeks postpartum.

RESULTS

We recruited 52 women who intended to breastfeed, among whom 47 completed 8-week follow-up. Duration and intensity of breastfeeding through 8 weeks were similar among mothers with lower versus higher anxiety and depression scores. In the third trimester, oxytocin was inversely correlated with Edinburgh Postnatal Depression Scale (EPDS) score (p=0.03). We did not find differences in neuroendocrine profile during breastfeeding at 2 weeks postpartum. Among the 39 women who breastfed at 8 weeks postpartum, oxytocin area under the curve during breastfeeding was inversely correlated with maternal EPDS and STAI-State and STAI-Trait anxiety scores (all p≤0.01). Higher anxiety and depression scores was further associated with lower oxytocin (group p<0.05) during feeding. During feeding at both visits, higher anxiety and depression scores were also associated with more negative affect: mothers reported feeling less happy and more depressed, overwhelmed, and stressed during feeding than women with lower scores.

CONCLUSION

Symptoms of depression and anxiety were associated with differences in oxytocin response and affect during breastfeeding.

Obsessive-compulsive symptoms during the postpartum period. A prospective cohort

OBJECTIVE

To estimate the prevalence of postpartum obsessive-compulsive disorder (OCD) symptoms and to ascertain risk factors for this condition.

STUDY DESIGN

This is a prospective cohort of postpartum women carried out from June to September 2009. A total of 461 women were recruited after delivery at a tertiary care institution. Demographic, psychiatric, and obstetric information were collected from each participant. Patients were contacted at 2 weeks and at 6 months postpartum and completed screening tests for depression, anxiety, and OCD.

RESULTS

Eleven percent of women screened positive for OCD symptoms at 2 weeks postpartum. At 6 months postpartum almost half of those women had persistent symptoms, and an additional 5.4% had developed new OCD symptoms. Concomitant positive screens for anxiety and depression were predictive factors for the development of OCD symptoms.

CONCLUSION

Prior population-based studies estimate the prevalence of OCD to be approximately 2-3%. We found much higher rates among women in the postpartum period. The postpartum period is a high-risk time for the development of OCD symptoms. When such symptoms develop, they have a high likelihood of persisting for at least 6 months.

Diagnosis and treatment of postpartum obsessions and compulsions that involve infant harm

Obsessive-compulsive symptoms in the postpartum period often include intrusive thoughts of harming the infant and rituals that result in avoidance of the baby. The differential diagnosis of women who develop these symptoms includes postpartum major mood disorders, obsessive-compulsive disorder, and psychosis with infanticidal thoughts. The treatment of the most common diagnoses, mood disorders and obsessive-compulsive disorder, includes serotonergic drugs, psychoeducation to help the patient understand that she is highly unlikely to harm her infant, and exposure with response prevention therapy. This intervention involves exposure of the patient to the feared situations, which are usually related to infant care, while simultaneously preventing the compulsive rituals.

Depression and anxiety in perinatal period: prevalence and risk factors in an Italian sample

Accumulating evidence suggests that pregnancy does not protect women from mental illness. The aim of this study was to assess the prevalence, sociodemographic correlates, and the risks factors for perinatal depression and anxiety. Five hundred ninety women between 28th and the 32nd gestational weeks were recruited and submitted to a sociodemographic, obstetric, and psychological interview. The Edinburgh Postnatal Depression Scale (EPDS) and the state-trait anxiety inventory (STAI-Y) were also administered in antenatal period and 3 months postnatally. The Structured Clinical Interview for DSM-IV (SCID-I) was used to diagnose mood and anxiety disorders. Three months after delivery, EPDS was administered by telephone interview. Women with an EPDS score ≥10 were 129 in antenatal period (21.9%) and 78 in postnatal period (13.2%). During pregnancy 121 women (20.5%) were positive for STAI-Y state and 149 women (25.3%) for STAI-Y trait. The most important risk factors for antenatal depression are: foreign nationality, conflictual relationship with family and partner, and lifetime psychiatric disorders. The principal risk factors for postnatal depression are: psychiatric disorders during pregnancy and artificial reproductive techniques. Psychiatric disorders, during and preceding pregnancy, are the strongest risk factors for antenatal state and trait anxiety. Antenatal depressive and anxiety symptoms appear to be as common as postnatal symptoms. These results provide clinical direction suggesting that early identification and treatment of perinatal affective disorders is particularly relevant to avoid more serious consequences for mothers and child.

Efficacy of a prevention program for postpartum obsessive-compulsive symptoms

Obsessive-Compulsive Disorder (OCD) has emerged as a common and impairing postpartum condition. Prospective studies have identified psychological vulnerabilities for the emergence of postpartum obsessive-compulsive symptoms (OCS), including general anxiety symptoms, pre-existing OCS, and specific cognitive distortions. The identification of these factors makes feasible the development of prevention programs that could reduce the impact of postpartum OCS. The present investigation examined a cognitive-behavioral prevention program using a randomized, double blind, controlled trial. Expecting mothers in their 2nd or 3rd trimester with an empirically established, malleable risk factor for postpartum OCS received either the prevention program (N=38) or a credible control program (N=33), both of which were incorporated into traditional childbirth education classes. Results revealed that at 1 month, 3 months, and 6 months postpartum, the prevention program was associated with significantly lower levels of obsessions and compulsions than was the control condition (all p's<0.05). Group differences remained significant even after controlling for baseline OCS and depression symptoms. Those in the prevention condition also reported decreasing levels of cognitive distortions, in contrast to the control condition (p's<0.05). Results support the potential utility of incorporating a CBT-based OCS prevention program into childbirth education classes.

The validity of DSM symptoms for depression and anxiety disorders during pregnancy

BACKGROUND

The applicability of the symptom criteria for diagnostic mood and anxiety disorders has in recent times been questioned for women in the perinatal period, due to the overlap of diagnostic symptoms with normal symptoms due to the physical changes of pregnancy or postpartum, (e.g., sleep difficulties).

METHOD

118 women in their second or early third trimester of pregnancy participated in a telephone interview that included the depression and anxiety modules of the MINI diagnostic interview, and an attributional probe question asking the woman whether endorsement of a symptom was due to the physical changes of her pregnancy or due to her mood or worries.

RESULTS

66% of pregnant women who met criteria for major depression reported that a sufficient number of their symptoms were due to the normal physical changes of their pregnancy, such that they would no longer meet criteria for a diagnosis of major depression. Attributional probing resulted in the rate of major depression falling from 6.8% to 1.7%. The impact on anxiety disorders appears to be less.

LIMITATIONS

An important issue is whether women's attributional perceptions are valid, though the face validity of some of their responses means that credence should be given to the findings. In addition, it would be useful from a validity perspective to undertake the same attributional probing with other populations where symptom presence is most likely due to mood, such as unemployed or recently separated adults without physical complaints.

CONCLUSION

Rates of depressive disorders in pregnancy, using DSM symptom criteria, are significantly over-estimated due to the natural occurrence of many of the symptoms as a result of the pregnancy. Rates of anxiety disorders are also inflated, but to a lesser degree. This means that the validation of self-report mood measures, typically done against DSM diagnoses, is likely to have produced erroneous findings (e.g., optimum cut-off scores). It is probable that a similar finding would be obtained for the postpartum period. Thus future use of DSM symptom criteria for depression and anxiety in perinatal mental health work should use some form of attributional probing question to more accurately understand the applicability of symptoms to a diagnosis in this population.

The Early Motherhood Service: an acceptable and accessible perinatal mental health service

OBJECTIVES

The aims of this paper are to quantify the effect of an innovative perinatal mental health program, the Early Motherhood Service, to identify factors contributing to its success, and to make recommendations as to its general applicability across other rural services.

METHOD

The study involved stakeholder evaluation, analysis of available outcome data and analysis of consumer feedback data.

RESULTS

Service functions were grouped into four key areas: increasing awareness of perinatal mental health problems; providing information and advice; providing treatment and support; and education, training and capacity building. Women accessing the service showed significant improvement in outcomes as measured by change over time in the Edinburgh Postnatal Depression Scale and the Health of the Nation Outcome Scale. Consumer feedback demonstrated that the service was highly valued. Key factors identified as contributing to the service's success were broad coverage of perinatal mental health problems; inclusion of early intervention and prevention; outreach capacity; partnership with, support for and capacity building of other health providers; a location which is accessible and non-stigmatizing; and staff comprising senior and skilled clinicians.

CONCLUSIONS

The Early Motherhood Service is an innovative perinatal mental health service. It provides a useful model for the development of such services in rural communities.

New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum

Maternal perinatal mental health has enormous consequences for the well-being of the mother, her baby, and the family. Although it is well documented that perinatal depression is both common and morbid, with a prevalence of 10% to 15% in the general population, there remain many critically important unanswered questions about the pathogenesis of perinatal depression and most effective treatment regimens. Current lines of evidence from both human and animal models implicate hormonal dysregulation, abnormalities in hypothalamic-pituitary-adrenal axis activity, and the contributions of genetics and epigenetics as playing key roles in the development of perinatal reproductive mood disorders. Investigations into both human and animal models of perinatal depression offer much promise for the future identification of the underlying pathophysiology and subsequent early identification and/or prevention and appropriate treatment for women at risk for postpartum depression. Lastly, although it is generally accepted that pregnancy is not protective with regard to new onset or relapse of depression, the way to best treat maternal depression during pregnancy and lactation remains hotly debated. Future research in this area will more clearly elucidate the underlying pathogenesis, the potential long-term impact of perinatal depression on the developing fetus, and how best to counsel pregnant women about the risks of untreated major depressive disorder versus the risks of psychopharmacologic treatment during pregnancy and lactation.