Pregnancy: a final frontier in mental health research

[Mother brain: Bayesian theory of maternal interoception during pregnancy and postpartum]

The perinatal period, including pregnancy and postpartum, causes major morphological, endocrinal, and thermal transitions in women. As the fetus grows, abdominal muscle fibers stretch, internal organs such as the bladder or colon move, and the uterine anatomy changes. Many of these changes involve interoception, the perception of internal body signals such as muscle and visceral sensations. Despite the importance of these interoceptive signals, few studies have explored perinatal interoception. We propose an innovative theory of maternal interoception based on recent findings in neuroscience. We show that interoceptive signals processing during pregnancy is crucial for understanding perinatal phenomenology and psychopathology, such as maternal perception of fetal movements, maternal-infant bonding, denial of pregnancy, phantom fetal movements after childbirth, pseudocyesis or even puerperal delusion. Knowing the importance of these interoceptive mechanisms, clinicians in obstetrics, gynecology and mental health should be particularly vigilant to maternal interoception during the perinatal period.

Engagement in and Benefits of a Short-Term, Brief Psychotherapy Intervention for PTSD During Pregnancy

Trauma-related symptoms and post-traumatic stress disorder (PTSD) are common during pregnancy and have adverse effects on pregnancy and birth outcomes, post-partum maternal mental health, and child development. The arousal symptoms associated with PTSD, including heightened or dysregulated physiology, may contribute to these adverse outcomes. Low-income minoritized women may be at highest risk given more lifetime exposure to trauma and limited access to mental health care. While evidence-based psychotherapies for PTSD exist, none are targeted to non-treatment seeking individuals nor specifically integrated with prenatal care. Thus, we developed and tested the efficacy of a short-term (four sessions) brief (30-45 min) psychotherapeutic intervention designed to address PTSD symptoms in pregnant women receiving prenatal care at two urban medical centers. Participants were 32 pregnant women with an average gestational age of 18.5 weeks at the time of enrollment. The sample was overwhelmingly non-Caucasian, single, and reported very low income. Participants completed measures of trauma-related symptoms (Post-traumatic Stress Disorder Checklist, PCL), and depression (Edinburgh post-natal Depression Scale, EPDS) at baseline, twice during treatment, post-treatment, and at 10-14 weeks post-partum. The intervention was successful at significantly decreasing symptoms of PTSD (PCL score = -20.27, 95% CI: -25.62, -14.92, P < 0.001, W = -7.43) and depression (EPDS score = -4.81, 95% CI: -7.55, -2.06, P = 0.001, W = -3.23) by the final session. These benefits were sustained at post-treatment and post-partum follow ups. Future research should further explore the effectiveness of this treatment in a randomized controlled trial.

Psychological Intervention and Treatment for Posttraumatic Stress Disorder During Pregnancy: A Systematic Review and Call to Action

Posttraumatic stress disorder (PTSD) during pregnancy is a significant global mental health concern that affects up to 1 in 5 trauma-exposed pregnant women and is associated with an increased risk of adverse maternal and infant complications and health outcomes. This systematic literature review, conducted in accordance with PRISMA guidelines, examined findings from studies of psychological interventions and treatments for prenatal PTSD to inform recommendations for future research. Relevant evidence was identified from reference reviews and electronic databases (i.e., PubMed, Google Scholar, PsychInfo, and Scopus). Included studies reported on the effect of nonpharmacological intervention or treatment of PTSD symptomatology delivered during pregnancy, with at least one postintervention follow-up collected during pregnancy to assess prenatal treatment outcomes. The systematic review was augmented with a discussion of lower-level evidence. Of the 954 articles screened, six peer-reviewed, quantitative reports met the inclusion criteria and featured three empirically based interventions, including two randomized controlled trials: Two psychoeducation interventions for PTSD and one treatment study of interpersonal psychotherapy in trauma-exposed pregnant women. Effect sizes for PTSD symptom change ranged from small to large, Cohen's d/η_p ² = 0.16-0.78. No studies examined evidence-based PTSD treatments (e.g., exposure therapy, cognitive processing therapy). A risk of bias assessment indicated variability in study quality. This review demonstrates that research on prenatal PTSD symptoms, diagnosis, and treatment is extremely limited despite a clear link between prenatal PTSD and perinatal complications. Early evidence supports further scientific inquiry into psychoeducation, psychotherapy treatments (e.g., exposure therapy), integrated prenatal care approaches, and community-based approaches.

Neurobiology of peripartum mental illness

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

"Phantom Kicks": Women's Subjective Experience of Fetal Kicks After the Postpartum Period

Background: During pregnancy, a woman will attribute increased abdominal sensations to fetal movement. Surprisingly, many women report that they feel kick sensations long after the pregnancy; however, this experience has never been reported in the scientific literature. Materials and Methods: We used a qualitative approach to survey n = 197 women who had previously been pregnant. We calculated the number of women who had experienced phantom kicks after their first pregnancy, and explored subjective experiences of kick-like sensations in the post-partum period. Results: In this study, we show that almost 40% of women in our sample experienced phantom fetal kicks after their first pregnancy, up to 28 years (average 6.4 years) post-partum. Women described the phantom sensations as "convincing," "real kicks," or "flutters." Twenty-seven percent of women described the experience as nostalgic or comforting, and 25.7% reported felt confused or upset by the experience. Conclusions: Our results demonstrate that phantom kicks in the postpartum period are a widely experienced sensation, which may have implications for a woman's postpartum mental health. The mechanism behind the phantom kick phenomenon is unknown, but may be related to changes in the somatosensory homunculus or proprioception during pregnancy.

Effect of sertraline on central serotonin and hippocampal plasticity in pregnant and non-pregnant rats

One of the most frequently prescribed selective serotonin reuptake inhibitor medications (SSRIs) for peripartum mood and anxiety disorders is sertraline (Zoloft®). Sertraline can help alleviate mood and anxiety symptoms in many women but it is not known how sertraline, or SSRIs in general, affect the neurobiology of the brain particularly when pregnant. The aim of this study was to investigate how sertraline affects plasticity in the hippocampus, a brain area integral in depression and SSRI efficacy (particularly in males), during late pregnancy and whether these effects differ from the effects of sertraline in non-pregnant females. To do this pregnant and age-matched non-pregnant female Sprague-Dawley rats were used. For the last half of pregnancy (10 days), and at matched points in non-pregnant females, rats were given sertraline (2.5 mg/kg/day or 10 mg/kg/day) or vehicle (0 mg/kg/day). Brains were used to investigate effects on the serotonergic system in the hippocampus and prefrontal cortex and measures of neuroplasticity in the hippocampus. Results show that pregnant females have significantly higher serum levels of sertraline compared to non-pregnant females but that rates of serotonin turnover in the hippocampus and PFC are similar between pregnant and non-pregnant females. Sertraline increased synaptophysin density in the dentate gyrus and CA3 and was associated with a decrease in cell proliferation in the dentate gyrus of non-pregnant, but not pregnant, females. During late pregnancy the hippocampus showed significant reductions in neurogenesis and increases in synaptophysin density. This research highlights the need to consider the unique effect of reproductive state on the neuropharmacology of SSRIs.