Do changes in subjective sleep and biological rhythms predict worsening in postpartum depressive symptoms? A prospective study across the perinatal period

Prospective Follow-Up of Adolescents With and at Risk for Depression: Protocol and Methods of the Identifying Depression Early in Adolescence Risk Stratified Cohort Longitudinal Assessments

Objective

To present the protocol and methods for the prospective longitudinal assessments-including clinical and digital phenotyping approaches-of the Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo) study, which comprises Brazilian adolescents stratified at baseline by risk of developing depression or presence of depression.

Method

Of 7,720 screened adolescents aged 14 to 16 years, we recruited 150 participants (75 boys, 75 girls) based on a composite risk score: 50 with low risk for developing depression (LR), 50 with high risk for developing depression (HR), and 50 with an active untreated major depressive episode (MDD). Three annual follow-up assessments were conducted, involving clinical measures (parent- and adolescent-reported questionnaires and psychiatrist assessments), active and passive data sensing via smartphones, and neurobiological measures (neuroimaging and biological material samples). Retention rates were 96% (Wave 1), 94% (Wave 2), and 88% (Wave 3), with no significant differences by sex or group (p > .05). Participants highlighted their familiarity with the research team and assessment process as a motivator for sustained engagement.

Discussion

This protocol relied on novel aspects, such as the use of a WhatsApp bot, which is particularly pertinent for low- to-middle-income countries, and the collection of information from diverse sources in a longitudinal design, encompassing clinical data, self-reports, parental reports, Global Positioning System (GPS) data, and ecological momentary assessments. The study engaged adolescents over an extensive period and demonstrated the feasibility of conducting a prospective follow-up study with a risk-enriched cohort of adolescents in a middle-income country, integrating mobile technology with traditional methodologies to enhance longitudinal data collection.

Sleep, circadian activity patterns and postpartum depression: A systematic review and meta-analysis of actigraphy studies

Transition to motherhood is a period full of challenges and demands. In this review, we focused on the associations of sleep and circadian activity patterns during and after pregnancy with postpartum mental health factors. A systematic review and meta-analysis were conducted (PROSPERO reference 316,505). A search for articles was performed using PsycARTICLES, PsycINFO, PubMed, MEDLINE, Scopus, Cochrane, DARE, hand search, and citation tracking. The search was meant to identify peer-reviewed, experimental and observational studies reporting on women over 18 years old that assessed sleep and circadian activity patterns during pregnancy or postpartum using actigraphy, and investigated postpartum mental health factors. Nineteen relevant publications were selected. Postpartum total sleep at night was the indicator that was most closely related to the psychological functioning of women after childbirth. The results of the systematic review indicated that postpartum total sleep at night was related to postpartum fatigue, and the results of the meta-analysis suggested that total sleep at night was most strongly linked with postpartum depression. More studies are needed to estimate the associations of sleep-wake rhythm during pregnancy and in the postpartum period with postpartum mental health factors.

A Feasibility Study to Assess Sleep and Subsequent Breast Milk Volume Among Mothers With Hospitalized Preterm Infants

BACKGROUND

Sleep is essential for optimal health, and disturbed postpartum sleep is associated with compromised infant attachment. The postpartum experience of mothers with preterm infants is unlike the biological norm, as they are separated from their infants and often express breast milk.

PURPOSE

The purpose of this study was to examine the feasibility of conducting a clinical research study among women with hospitalized preterm infants. We also explored for associations between maternal sleep patterns and sleep-related psychological states and subsequent breast milk volume.

METHODS

Participants were recruited from Magee-Womens Hospital, located in Pittsburgh, Pennsylvania New mothers completed daily sleep and pumping logs and scales to measure stress, trauma, depression, fatigue, and sleep quality.

RESULTS

A total of 78 women were screened, 18 women consented, and a total of 8 participants completed the study. Screening from the postpartum unit increased recruitment. The participants experience worsening sleep quality over time, moderate stress, and fatigue. Stress, postnatal depression, and fatigue are negatively associated with milk volume.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Postpartum recruitment with frequent follow-ups improved recruitment and retention. We present a preliminary association between maternal stress, fatigue, and depression, and subsequent breast milk volume. Sleep-related psychological states may negatively influence milk volume.

Sleep, light exposure at night, and psychological wellbeing during pregnancy

BACKGROUND

Psychological wellbeing during pregnancy is imperative for optimal maternal outcomes. The present study aimed to determine the association between sleep quality, light exposure at night, and psychological wellbeing in the 2nd and 3rd trimesters of pregnancy.

METHODS

This prospective study was conducted in 9 randomly selected government maternity clinics in Kuala Lumpur, Malaysia. Healthy women aged 20-48 years old with single pregnancy were recruited using convenience sampling (n = 169). Sleep quality, light exposure at night, and psychological wellbeing were self-reported using the Pittsburgh Sleep Quality Index (PSQI), Harvard Light Exposure Assessment (H-LEA), and Depression, Anxiety, and Stress Scale (DASS-21) in the 2nd trimester and followed-up at the 3rd trimester.

RESULTS

During the 2nd and 3rd trimesters of pregnancy, mild to severe symptoms of stress (10.7 and 11.3%), anxiety (42 and 44.3%), and depression (9.6 and 16.6%) were observed among the participants. Adjusted multiple linear regression revealed that poor sleep quality and higher light exposure at night were attributed to greater stress and depression symptoms in the 3rd trimester. Higher lux level exposed from 10 pm to < 1 am was associated with increased stress (β = 0.212, p = 0.037) and depression (β = 0.228, p = 0.024). Only poor sleep quality was observed to adversely affect anxiety (β = 0.243, p = 0.002) and depression levels (β = 0.259, p = 0.001) in the 2nd trimester.

CONCLUSIONS

Present study provided preliminary findings on the association between sleep quality, light at night, and psychological wellbeing of pregnant women. As a recommendation, future research could investigate whether public health interventions aimed at decreasing artificial light at night can benefit sleep quality and the psychological health of pregnant women.

Association between sleep disorders during pregnancy and risk of postpartum depression: a systematic review and meta-analysis

Sleep disorders are common among pregnant females. However, its association with postpartum depression (PPD) is unknown. We aimed to assess if sleep disorders during pregnancy increase the risk of PPD by a systematic review. The databases of PubMed, CENTRAL, ScienceDirect, Embase, and Google Scholar were searched for studies reporting the association between any type of sleep disorder during pregnancy and the risk of PPD. Effect sizes were pooled in a random-effects model. Sixteen studies with data of 12,614 women were included. Meta-analysis indicated that sleep disorders during pregnancy resulted in a statistically significant increased risk of PPD (OR: 2.36 95% CI: 1.72, 2.32). The overall result had high heterogeneity (I² = 84%). Sub-group analysis based on study location (Asian vs Western), sample size (> 500 vs < 500), depression scale, and PPD assessment time did not change the results. However, we found that only poor sleep quality but not insomnia was associated with PPD. The risk was also increased only with sleep disorders measured in the 3rd trimester but not for the 1st and 2nd trimesters. Evidence suggests that sleep disorders during pregnancy may increase risk of PPD. The risk is high for sleep disorders occurring in the 3rd trimester. Based on these findings, there is a need for thorough screening and subsequent corrective measures to ensure adequate and quality sleep among pregnant females.

Post-partum depression: From clinical understanding to preclinical assessments

Post-partum depression (PPD) with varying clinical manifestations affecting new parents remains underdiagnosed and poorly treated. This minireview revisits the pharmacotherapy, and relevant etiological basis, capable of advancing preclinical research frameworks. Maternal tasks accompanied by numerous behavioral readouts demand modeling different paradigms that reflect the complex and heterogenous nature of PPD. Hence, effective PPD-like characterization in animals towards the discovery of pharmacological intervention demands research that deepens our understanding of the roles of hormonal and non-hormonal components and mediators of this psychiatric disorder.

Multidimensional self-rating biological rhythm disorder and its association with depression and anxiety symptoms among adolescents aged 11-23 years: a school-based cross-sectional study from China

BACKGROUND

Depression and anxiety are topical concerns worldwide, especially among adolescents. Besides, biological rhythm disorder as a candidate mechanism for mood disorders is highly prevalent, but relevant research among adolescents in China is presently limited. We conducted the present study to investigate the distribution of multi-dimensional self-rating biological rhythm disorder and the association of self-rating biological rhythm disorders with depression and anxiety symptoms among Chinese adolescents in different academic stages.

METHODS

In the cross-sectional study, 3693 students aged 11-23 from Zhengzhou City, Henan Province, China were included. The Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) were used to evaluate symptoms of depression and anxiety, respectively. Additionally, the Self-Rating of Biological Rhythm Disorder for Adolescents (SBRDA) was used to assess status of biological rhythm disorders. Multivariate logistic regression was developed to explore factors potentially associated with symptoms of depression and anxiety stratified by academic stages.

RESULTS

Among all participants, 44.14 and 36.15% suffered from depression and anxiety symptoms, respectively. On average, participants scored 74.66 ± 19.37 on the measure of total biological rhythm disorder. Adjusted for demographic confounding factors, the logistic regression analysis showed higher scores of total biological rhythm disorder were associated with more severe depression (OR = 14.38, 95%CI: 11.38-18.16) and anxiety symptoms (OR = 11.63, 95%CI: 9.14-14.81). The similar results were also found in the stratified analysis by academic stages.

CONCLUSIONS

Self-rating biological rhythm disorders are significantly associated with depression and anxiety symptoms among adolescents. Discrepancy across academic stages should also be taken into account in establishing public health strategies.

Similarities and differences between postpartum depression and depression at other stages of female life: a systematic review

BACKGROUND

Women are nearly twice as likely as men to suffer from depression throughout the life span. In particular, reproductive transition phases mark a period of vulnerability for female mood disorders. The life events of being pregnant and giving birth harbor multiple psychological and physiological challenges, and a lack of adjustment to these events can result in mood swings and depression. The purpose of this review is to provide an overview of the symptomatology of postpartum depression (PPD), including tools that have been used to assess PPD, and potential phenomenological differences to major depression during other life phases.

METHODS

A systematic literature search in the databases PubMed, Cochrane Library and PsycINFO was conducted with the keywords "postpartum depression" and "symptomatology". A total of 33 studies fulfilled the chosen criteria and were selected for the review.

RESULTS

Within the studies, 22 different tools were used to assess depressive symptoms throughout pregnancy and the postpartum period. A total of 29 questionnaires or interviews were applied to detect additional psychopathological symptoms present in the perinatal period, such as anxiety. Most studies that included a control group of non-perinatal women concluded that postpartum depression is nosologically distinct from depression occurring at other stages of female life.

DISCUSSION

Somatic symptoms in the puerperium contribute to psychopathological burden and might result in diverse clinical representations of postpartum depression. Anxiety frequently co-occurs with depression during the perinatal period. However, the diversity of screening instruments for postpartum depression does not allow for general conclusions to be drawn about similarities or differences in the psychopathological profiles of postpartum women with depression and women with depression at other stages of life.

Associations among fear of childbirth, resilience and psychological distress in pregnant women: A response surface analysis and moderated mediation model

INTRODUCTION

Prenatal psychological distress is prevalent during pregnancy. This study aimed to estimate the associations among fear of childbirth, resilience and psychological distress.

METHODS

A total of 1,060 Chinese pregnant women were enrolled from Be Resilient to Postpartum Depression (ChiCTR2100048465) and the following instruments were administered to them: Childbirth Attitudes Questionnaire, Connor-Davidson Resilience Scale, Perceived Social Support Scale, General Self-Efficacy Scale, Adverse Childhood Experience scale and Hospital Anxiety and Depression Scale. A dominance, a response surface analysis and a moderated mediation analysis were performed.

RESULTS

In terms of psychological distress, resilience and fear of childbirth could explain 41.6% (0.148/0.356) and 33.1% (0.118/0.356), respectively. Pregnant women with high resilience-low fear of childbirth had significantly lower levels of psychological distress than those with low resilience-high fear of childbirth. The indirect effects of fear of childbirth on psychological distress through resilience was significantly (B = 0.054, 95% CI 0.038 to 0.070). The interactions between fear of childbirth and adverse childhood experiences (β = 0.114, 95% CI -0.002 to 0.231, p = 0.054) and between resilience and adverse childhood experiences (β = -0.118, 95% CI -0.222 to -0.012, p < 0.05) were significant.

CONCLUSION

Resilience, fear of childbirth and adverse childhood experiences may be three important factors to psychological distress in Chinese pregnant women.

Sleep, biological rhythms and anxiety in the perinatal period: a systematic review protocol

INTRODUCTION

Pregnancy and new parenthood is an exciting time, but also a stressful life event that can predispose to mental health challenges. Perinatal anxiety is one such challenge, and is an important contributor to parental distress and other negative outcomes. Sleep and biological rhythms are often disrupted in the perinatal period. These disruptions have been associated with postpartum depression, and in some cases with perinatal anxiety. However, the literature concerning the association with perinatal anxiety is inconsistent and may be methodologically limited. To our knowledge, there has been no comprehensive review published characterising the relationships between sleep, biological rhythms, and perinatal anxiety and related disorders to date. In this systematic review, we will summarise the current state of the literature concerning these relationships, allowing us to highlight gaps and potentially inform clinical understanding of perinatal anxiety, sleep and biological rhythms.

METHODS AND ANALYSIS

Primary research articles will be eligible for inclusion if they assess perinatal anxiety or related disorders using validated criteria (self-report or diagnostic), assess sleep and biological rhythms in the perinatal period, include >4 participants and meet other inclusion/exclusion criteria. We will conduct comprehensive searches of MEDLINE, PsycINFO, Embase and CINAHL, with coverage spanning from database conception to search date (August 1, 2021). Key search concepts include (1) the perinatal period, (2) sleep/biological rhythms and (3) anxiety. Risk of bias will be evaluated using the Cochrane Risk of Bias Tool. Data will be narratively synthesised, with quantitative synthesis included if possible. When relevant, strength of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation criteria, and potential publication bias will be assessed.

ETHICS AND DISSEMINATION

Research ethics approval is not required. Study results will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results will be disseminated to relevant stakeholders as conference presentation(s) and submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

200166.

Evaluation of salivary melatonin concentrations as a circadian phase maker of morning awakening and their association with depressive mood in postpartum mothers

The disruption of circadian rhythm is closely related to mood disorders in night-shift workers, and a similar situation may occur in postpartum mothers. However, the situations of postpartum mothers remain largely unknown because of a lack of an appropriate circadian phase marker in the clinical setting. This study aimed to evaluate whether salivary melatonin concentration at awakening can identify misalignment between awakening time and the biological clock system, which might be associated with depressive mood in some mothers. Ninety-eight healthy mothers who were currently the primary parental caregivers were recruited at 1 month after delivery. All mothers completed the Edinburgh Postnatal Depression Scale (EPDS) and wore an actigraphy watch at home for 3 consecutive days to determine nocturnal sleep variables. While wearing the actigraphy watch, they also collected saliva samples during the awakening period for a melatonin concentration assay. The results indicated that daily salivary melatonin levels after 30 min of awakening (hereafter, melatonin levels) were positively correlated with sleep onset time and negatively correlated with sleep offset time and total sleep time. Six mothers with an EPDS score of ≥9 (the cutoff value for Japanese women at high risk for postnatal depression) had an average melatonin level of either <4 pg/ml or >16 pg/ml for 3 d. Mothers with melatonin levels <4 pg/ml or >16 pg/ml tended to have elevated EPDS scores (4.93 ± 2.95 or 4.20 ± 2.93, mean ± standard deviation) compared with mothers with melatonin levels between 4 and 16 pg/ml (3.00 ± 2.12, p = .053). Mothers whose melatonin levels were >16 pg/ml had relatively later sleep onset time and shorter nocturnal sleep duration. Backward stepwise regression demonstrated that such high/low levels of melatonin were a significant predictor of EPDS scores. These results suggest that elevated melatonin levels after 30 min of awakening could identify a phase-delayed circadian rhythm in postpartum mothers, and that relatively higher or lower melatonin levels could be associated with increased depressive mood.

Sleep disorders during pregnancy and postpartum depression: A systematic review and meta-analysis

BACKGROUND

Postpartum depression (PPD) is one of the most important mental disorders in recent years. However, the effects of prenatal sleep disorders on the development of PPD among pregnant women have not been elucidated. This review aims to provide a summary of the literature evaluating the relation between sleep disorders during pregnancy and PPD.

METHOD

A systematic literature search was conducted in PubMed, Web of Science, Scopus, Google Scholar, and Embase up to September 2020. All observational studies (cross-sectional, case-control, and cohort) and studies that assessed the association between sleep disorders during pregnancy and PPD were included. Total sample of 36,873 women from 13 studies was entered to meta-analysis. An aggregate effect size estimate (odds ratio) was generated using the comprehensive meta-analysis software. A random effects model was set a priori. Heterogeneity and publication bias were examined using the standard meta-analytic approaches.

RESULT

We found maternal sleep disorder increased odds of PPD (point estimate, 3.300; 95% confidence interval [CI], 2.136-5.098; p < .001; n = 13). However, there was significant heterogeneity (Q, 131.250; df, 12; p < .001; I² , 90.857%). The estimated effect size was significant for all categorical studies. According to meta-regression, no moderating factor (age and publication year) significantly mediated the estimated effect size.

CONCLUSION

We found a significant relationship between sleep disturbances during pregnancy and PPD. Women with sleep disorders are at an increased risk of developing PPD, which warrants screening pregnant mothers for sleep disturbances. Also, we found that the increasing age in pregnancy was associated with increased risk of PPD.

Passive sensing on mobile devices to improve mental health services with adolescent and young mothers in low-resource settings: the role of families in feasibility and acceptability

BACKGROUND

Passive sensor data from mobile devices can shed light on daily activities, social behavior, and maternal-child interactions to improve maternal and child health services including mental healthcare. We assessed feasibility and acceptability of the Sensing Technologies for Maternal Depression Treatment in Low Resource Settings (StandStrong) platform. The StandStrong passive data collection platform was piloted with adolescent and young mothers, including mothers experiencing postpartum depression, in Nepal.

METHODS

Mothers (15-25 years old) with infants (< 12 months old) were recruited in person from vaccination clinics in rural Nepal. They were provided with an Android smartphone and a Bluetooth beacon to collect data in four domains: the mother's location using the Global Positioning System (GPS), physical activity using the phone's accelerometer, auditory environment using episodic audio recording on the phone, and mother-infant proximity measured with the Bluetooth beacon attached to the infant's clothing. Feasibility and acceptability were evaluated based on the amount of passive sensing data collected compared to the total amount that could be collected in a 2-week period. Endline qualitative interviews were conducted to understand mothers' experiences and perceptions of passive data collection.

RESULTS

Of the 782 women approached, 320 met eligibility criteria and 38 mothers (11 depressed, 27 non-depressed) were enrolled. 38 mothers (11 depressed, 27 non-depressed) were enrolled. Across all participants, 5,579 of the hour-long data collection windows had at least one audio recording [mean (M) = 57.4% of the total possible hour-long recording windows per participant; median (Mdn) = 62.6%], 5,001 activity readings (M = 50.6%; Mdn = 63.2%), 4,168 proximity readings (M = 41.1%; Mdn = 47.6%), and 3,482 GPS readings (M = 35.4%; Mdn = 39.2%). Feasibility challenges were phone battery charging, data usage exceeding prepaid limits, and burden of carrying mobile phones. Acceptability challenges were privacy concerns and lack of family involvement. Overall, families' understanding of passive sensing and families' awareness of potential benefits to mothers and infants were the major modifiable factors increasing acceptability and reducing gaps in data collection.

CONCLUSION

Per sensor type, approximately half of the hour-long collection windows had at least one reading. Feasibility challenges for passive sensing on mobile devices can be addressed by providing alternative phone charging options, reverse billing for the app, and replacing mobile phones with smartwatches. Enhancing acceptability will require greater family involvement and improved communication regarding benefits of passive sensing for psychological interventions and other health services. Registration International Registered Report Identifier (IRRID): DERR1-10.2196/14734.

The Revised Mood Rhythm Instrument: A Large Multicultural Psychometric Study

Background: Recent studies with the mood rhythm instrument (MRhI) have shown that the presence of recurrent daily peaks in specific mood symptoms are significantly associated with increased risk of psychiatric disorders. Using a large sample collected in Brazil, Spain, and Canada, we aimed to analyze which MRhI items maintained good psychometric properties across cultures. As a secondary aim, we used network analysis to visualize the strength of the association between the MRhI items. Methods: Adults (n = 1275) between 18–60 years old from Spain (n = 458), Brazil (n = 415), and Canada (n = 401) completed the MRhI and the self-reporting questionnaire (SRQ-20). Psychometric analyses followed three steps: Factor analysis, item response theory, and network analysis. Results: The factor analysis indicated the retention of three factors that grouped the MRhI items into cognitive, somatic, and affective domains. The item response theory analysis suggested the exclusion of items that displayed a significant divergence in difficulty measures between countries. Finally, the network analysis revealed a structure where sleepiness plays a central role in connecting the three domains. These psychometric analyses enabled a psychometric-based refinement of the MRhI, where the 11 items with good properties across cultures were kept in a shorter, revised MRhI version (MRhI-r). Limitations: Participants were mainly university students and, as we did not conduct a formal clinical assessment, any potential correlations (beyond the validated SRQ) cannot be ascertained. Conclusions: The MRhI-r is a novel tool to investigate self-perceived rhythmicity of mood-related symptoms and behaviors, with good psychometric properties across multiple cultures.

Poor Sleep and Decision-Making Disturbance Are Associated With Suicidal Ideation in Pre-natal Depression

Although many risk factors for suicidal ideation have been identified, few studies have focused on suicidal ideation and pre-natal depression. The purpose was to investigate the relationship between decision-making (DM) dysfunction and sleep disturbance on suicidal ideation in pre-natal depression. Participants included 100 women in the third trimester of pregnancy, including pregnant women with pre-natal depression who had recent suicidal ideation (n = 30), pre-natal depression without SI (n = 35) and healthy controls (n = 35). The Iowa Gambling Task (IGT) was used to evaluate the DM function and the Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep index. The Edinburgh Post-natal Depression Scale (EPDS) was used to assess suicidal ideation and the seriousness of depression. Overall, the two groups with pre-natal depression showed worse sleep quality and decreased DM function compared with healthy controls. The pre-natal depression with suicidal ideation group showed a significantly higher score in subjective sleep quality and a lower score in block 5 of IGT than the pre-natal depression without suicidal ideation group. Further correlation analysis showed that suicidal ideation positively correlated with subjective sleep quality, sleep duration, and daytime function, and negatively correlated with IGT scores. Sleep disturbance and impaired DM function may be risk factors for suicidal ideation in pre-natal depression.

Toward prevention of bipolar disorder in at-risk children: Potential strategies ahead of the data

BACKGROUND

Despite the well-documented negative impact of untreated bipolar illness, approaches to early intervention in childhood-onset bipolar and related disorders are not well delineated.

METHODS

We reviewed the extant treatment literature on children at high risk for bipolar disorder, with definitions based on family history, childhood adversity, and prodromal symptoms.

RESULTS

A panoply of approaches have been described, but most interventions are based on an inadequate database to support their routine implementation. We classify early stage interventions as a function of their safety and tolerability with the hope that these might generate more rigorous study and a stronger database.

LIMITATIONS

Critics may rightly argue that identifying viable treatment methods is premature given our lack of ability to reliably predict illness trajectory in very young children. However, many of the psychosocial and pharmacological interventions we present could have nonspecific positive effects across a variety of symptoms, syndromes, and diagnoses, further enhancing the rationale for more rigorous study.

CONCLUSIONS

Early stage interventions have the potential to improve functioning in prodromal illness and exert long-term positive effects on the course of illness. Many of the safest interventions deserve consideration for implementation and dissemination studies.

Indicators of vulnerability associated with less healthy circadian rhythms in undergraduate medical interns

To evaluate the association between circadian health parameters and psychological and biological vulnerability, a cross-sectional study was conducted with 15 undergraduate medical interns using the Brief Resilience Scale, the Mini International Neuropsychiatric Interview, and an ambulatory circadian monitoring device. Circadian Health construct was confirmed by factor analysis. Vulnerability factors (history of depression and low resilience) were associated to lower circadian health of motor activity and temperature rhythms. The findings suggest that not only being depressed but also having had depressive episodes in the past, as well as having low resilience, are associated with chronodisruption, and may increase the risk for developing new episodes of depression.

Use of Prescribed Psychotropics during Pregnancy: A Systematic Review of Pregnancy, Neonatal, and Childhood Outcomes

This paper reviews the findings from preclinical animal and human clinical research investigating maternal/fetal, neonatal, and child neurodevelopmental outcomes following prenatal exposure to psychotropic drugs. Evidence for the risks associated with prenatal exposure was examined, including teratogenicity, neurodevelopmental effects, neonatal toxicity, and long-term neurobehavioral consequences (i.e., behavioral teratogenicity). We conducted a comprehensive review of the recent results and conclusions of original research and reviews, respectively, which have investigated the short- and long-term impact of drugs commonly prescribed to pregnant women for psychological disorders, including mood, anxiety, and sleep disorders. Because mental illness in the mother is not a benign event, and may itself pose significant risks to both mother and child, simply discontinuing or avoiding medication use during pregnancy may not be possible. Therefore, prenatal exposure to psychotropic drugs is a major public health concern. Decisions regarding drug choice, dose, and duration should be made carefully, by balancing severity, chronicity, and co-morbidity of the mental illness, disorder, or condition against the potential risk for adverse outcomes due to drug exposure. Globally, maternal mental health problems are considered as a major public health challenge, which requires a stronger focus on mental health services that will benefit both mother and child. More preclinical and clinical research is needed in order to make well-informed decisions, understanding the risks associated with the use of psychotropic medications during pregnancy.

Wearable Digital Sensors to Identify Risks of Postpartum Depression and Personalize Psychological Treatment for Adolescent Mothers: Protocol for a Mixed Methods Exploratory Study in Rural Nepal

BACKGROUND

There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression.

OBJECTIVE

This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment.

METHODS

This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives.

RESULTS

To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019.

CONCLUSIONS

Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14734.

Sleeping problems during pregnancy-a risk factor for postnatal depressiveness

In the general population, sleeping problems can precede an episode of depression. We hypothesized that sleeping problems during pregnancy, including insomnia symptoms, shortened sleep, and daytime tiredness, are related to maternal postnatal depressiveness. We conducted a prospective study evaluating sleep and depressive symptoms, both prenatally (around gestational week 32) and postnatally (around 3 months after delivery) in the longitudinal CHILD-SLEEP birth cohort in Finland. Prenatally, 1667 women returned the questionnaire, of which 1398 women participated also at the postnatal follow-up. Sleep was measured with the Basic Nordic Sleep Questionnaire (BNSQ) and depressive symptoms with a 10-item version of the Center for Epidemiological Studies Depression Scale (CES-D). Altogether, 10.3% of the women had postnatal depressiveness (CES-D ≥ 10 points). After adjusting for main background characteristics and prenatal depressiveness (CES-D ≥ 10), poor general sleep quality (AOR 1.87, 95% CI 1.21-2.88), tiredness during the day (AOR 2.19, 95% CI 1.41-3.38), short sleep ≤ 6 and ≤ 7 h, sleep latency > 20 min, and sleep loss ≥ 2 h were associated with postnatal depressiveness (all p < .050). Postnatally, after the adjustment for background characteristics, virtually all sleeping problems (i.e., difficulty falling asleep (AOR 7.93, 95% CI 4.76-13.20)), except frequent night awakenings per week or severe sleepiness during the day, were related to concurrent postnatal depressiveness. Thus, several prenatal and postnatal sleeping problems are associated with increased depressive symptoms 3 months postnatally. Screening of maternal prenatal sleeping problems, even without depressive symptoms during pregnancy or lifetime, would help to identify women at an increased risk for postnatal depressiveness.

Pregnant pause: should we screen for sleep disordered breathing in pregnancy?

Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level.

Untreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but thresholds for and effectiveness of intervention are unclear. Clinicians should use shared decision making for screening and treatment decisions.http://ow.ly/N0oN30noWnx

Poor sleep quality of third trimester exacerbates the risk of experiencing postnatal depression

This study sought to investigate the effects of subjectively-determined poor prenatal sleep quality on postnatal depression (PND), after adjusting for prenatal psychological distress and perceived stress. From March 2016 to December 2017, we conducted a prospective longitudinal study using a convenience sample of 228 perinatal women. The participants completed the Pittsburgh Sleep Quality Index (PSQI), the 10-item Kessler Psychological Distress Scale (K10) and the Perceived Stress Scale (PSS) during the third trimester (Time 1 or T1), and completed the Edinburgh Postnatal Depression Scale (EPDS) at 1 months postpartum (Time 2 or T2). Logistic regression analyses were used to analyze the associations between subjective prenatal sleep quality and postnatal depression. The results showed that prenatal psychological distress (OR = 2.551, 95% CI = 1.221 ~ 5.329, P = 0.013) and perceived stress (OR = 2.881, 95% CI = 1.398 ~ 5.938, P= 0.007) were the strongest predictors of PND. Independent of this, poor subjective sleep quality (OR = 2.391, 95% CI = 1.072 ~ 5.556, P = 0.044) during pregnancy also predicted postnatal depressive symptoms. Treatment of psychological distress and perceived stress appears important for reducing the incidence of PND. Nonetheless, future studies might explore treatments to improve prenatal sleep quality.

The Role of Circadian Rhythms in Postpartum Sleep and Mood

Women often experience sleep disturbances and worsening sleep quality throughout pregnancy and postpartum. Circadian rhythms are closely linked to sleep problems and mood disorders. This systematic review provides a summary of studies of circadian rhythms and associated sleep problems and maternal distress, among postpartum women. Articles were idenitfied through a systematic literature search. Circadian rhythm disturbances were strongly correlated with depression, social factors and mothers`s exposure to light postpartum. Future research should include larger, prospective studies as well as randomized controlled trials for measuring effect of circadian rhythm interventions on postpartum mental health outcomes.

Poor sleep quality increases symptoms of depression and anxiety in postpartum women

This study evaluated the relationship between sleep quality and symptoms of depression and anxiety in women studied in pregnancy and postpartum. Scores on standardized measures of sleep (PSQI) at 6 months postpartum, and symptoms of anxiety and depression (OASIS, the PHQ9, and EPDS) were assessed by structured interviews in 116 women in pregnancy and/or postpartum. Poor sleep quality was significantly associated with greater symptoms of depression and anxiety. Women who had significantly higher OASIS (anxiety) scores (β = .530, p < .001), PHQ9 (depression) scores (β = .496, p < .001), and EPDS (postpartum depression and anxiety) scores (β = .585, p < .001) also had elevated total PSQI scores after adjustment for covariates, including prenatal depression and anxiety scores. Though inferences about causality are not feasible, these results support emerging research showing sleep quality is a risk factor for negative maternal affect in the postpartum period. Assessment of maternal sleep hygiene is worth consideration as a component of identifying women at risk for postpartum depression and anxiety.

Performance of the biological rhythms interview for assessment in neuropsychiatry: An item response theory and actigraphy analysis

BACKGROUND

Biological rhythm disturbances are widely associated with the pathophysiology of mood disorders. The Biological Rhythms Interview for Assessment in Neuropsychiatry (BRIAN) is a self-report that indexes rhythm disturbance in sleep, activity, social and eating patterns. The aim of this study was to perform an Item Response Theory (IRT) analysis of the BRIAN and investigate its associations with objective sleep and rhythm disturbance measures.

METHODS

103 subjects (31 bipolar, 32 major depression and 40 healthy volunteers) wore an actiwatch for fifteen days, and completed a first morning urine sample and the BRIAN on day 15. IRT analysis assessed individual BRIAN items and their relationship to total score. Individual actiwatch records were processed to produce a sequence of transitions between rest/activity, and a likelihood of transitioning between states was calculated to investigate sleep-wake dynamics. Cosinor analysis produced daily activity rhythms (DARs). Spearman correlations were used to assess the association between sleep/DAR variables and the BRIAN.

RESULTS

IRT analyses showed that 11 of 18 BRIAN items displayed a high level of discrimination between item options across a range of BRIAN total scores. Total BRIAN score correlated with wake after sleep onset, total activity count during sleep, and urinary 6-sulphatoxymelatonin. BRIAN Activity domain correlated with the daytime transition probability from rest to activity.

LIMITATIONS

The sample size may have been underpowered for the graded-response model employed in IRT. The study lacked an objective comparison for BRIAN eating and social domain.

CONCLUSION

The present study reveals the BRIAN displays promising external validity compared to objective parameters of circadian rhythmicity.

A closer look at the preventative effect of antidepressants in postpartum depression

Antidepressants are commonly recommended for prevention of postpartum depression; however, there is a lack of clarity about their role in the reduction of postpartum recurrences. Surprisingly, there are only two randomized controlled trials, one open trial, and one prospective cohort study on the subject. Evidence in support of the use of antidepressants is limited to a study of only 22 women. Due to the paucity of extant literature, no firm conclusions can be drawn about the prophylactic efficacy of antidepressants.

Transforming Life: A Broad View of the Developmental Origins of Health and Disease Concept from an Ecological Justice Perspective

The influential scientist Rene J. Dubos (1901–1982) conducted groundbreaking studies concerning early-life environmental exposures (e.g., diet, social interactions, commensal microbiota, housing conditions) and adult disease. However, Dubos looked beyond the scientific focus on disease, arguing that “mere survival is not enough”. He defined mental health as fulfilling human potential, and expressed concerns about urbanization occurring in tandem with disappearing access to natural environments (and elements found within them); thus modernity could interfere with health via “missing exposures”. With the advantage of emerging research involving green space, the microbiome, biodiversity and positive psychology, we discuss ecological justice in the dysbiosphere and the forces—financial inequity, voids in public policy, marketing and otherwise—that interfere with the fundamental rights of children to thrive in a healthy urban ecosystem and learn respect for the natural environment. We emphasize health within the developmental origins of health and disease (DOHaD) rubric and suggest that greater focus on positive exposures might uncover mechanisms of resiliency that contribute to maximizing human potential. We will entrain our perspective to socioeconomic disadvantage in developed nations and what we have described as “grey space”; this is a mental as much as a physical environment, a space that serves to insidiously reinforce unhealthy behavior, compromise positive psychological outlook and, ultimately, trans-generational health. It is a dwelling place that cannot be fixed with encephalobiotics or the drug-class known as psychobiotics.

Disturbed Sleep and Postpartum Depression

The perinatal period introduces a myriad of changes. One important but often overlooked change is an increased reporting of sleep disturbance. Although casually regarded as a consequence of pregnancy or postpartum, there is emerging evidence implicating significant sleep disturbance, characterized by insomnia symptoms and/or poor sleep quality, with adverse outcomes, such as an increase in depressive symptomatology or the development postpartum depression (PPD). Significant consequences may arise as a result including issues with maternal-infant bonding, effective care for the infant, and behavioral or emotional difficulties in the infant. This review discusses the relevant literature as to how disturbed sleep during pregnancy as well as in the postpartum may increase the risk for PPD.