Perinatal psychiatric disorders: an overview

Association between maternal mental health-related hospitalisation in the 5 years prior to or during pregnancy and adverse birth outcomes: a population-based retrospective cohort data linkage study in the Northern Territory of Australia

Background

Mental health conditions prior to or during pregnancy that are not addressed can have adverse consequences for pregnancy and birth outcomes. This study aimed to determine the extent to which women's mental health-related hospitalisation (MHrH) prior to or during pregnancy was associated with a risk of adverse birth outcomes.

Methods

We linked the perinatal data register for all births in the Northern Territory, Australia, from the year 1999 to 2017, to hospital admissions records to create a cohort of births to women aged 15-44 years with and without MHrH prior to or during pregnancy. We used Modified Poisson Regression and Latent Class Analysis to assess the association between maternal MHrH and adverse birth outcomes (i.e., stillbirth, preterm birth, low birth weight, and short birth length). We explored a mediation effect of covariates on theoretical causal paths. We calculated the adjusted Population Attributable Fraction (PAF) and Preventive Fractions for the Population (PFP) for valid associations.

Findings

From 72,518 births, 70,425 births (36.4% for Aboriginal women) were included in the analysis. The Latent Class Analys identified two classes: high (membership probability of 10.5%) and low adverse birth outcomes. Births to Aboriginal women with MHrH were around two times more likely to be in the class of high adverse birth outcomes. MHrH prior to or during pregnancy increased the risk of all adverse birth outcomes in both populations with risk ranging from 1.19 (95% CI: 1.05, 1.35) to 7.89 (1.17, 53.37). Eight or more antenatal care visits and intrauterine growth restriction mostly played a significant mediation role between maternal MHrH and adverse birth outcomes with mediation effects ranging from 1.04 (1.01, 1.08) to 1.39 (1.14, 1.69). MHrH had a low to high population impact with a PAF ranging from 16.1% (5.1%, 25.7%) to 87.3% (14.3%, 98.1%). Eight or above antenatal care visits avert extra adverse birth outcomes that range from 723 (332-765) stillbirths to 3003 (1972-4434) preterm births.

Interpretation

Maternal MHrH is a modifiable risk factor that explained a low to moderate risk of adverse birth outcomes in the Northern Territory. The knowledge highlights the need for the development and implementation of preconception mental health care into routine health services.

Funding

The Child and Youth Development Research Partnership (CYDRP) data repository is supported by a grant from the Northern Territory Government.

Obsessive-compulsive disorder symptoms and intrusive thoughts in the postpartum period: Associations with trauma exposure and PTSD symptoms

In a community sample of trauma-exposed postpartum individuals (N = 167; mean age = 30, 90% White; 61.7% completed bachelor's degree or higher) longitudinally completed self-report measures on PTSD, depressive, and Obsessive-compulsive disorder (OCD) symptoms (specifically checking, ordering, washing, and obsessing symptoms), preoccupation with intrusive postpartum thoughts/neutralising strategies, and trauma exposure at 4 and 12 weeks postpartum. PTSD symptoms were strongly associated with all OCD symptoms (r = 0.32- 0.49, p < 0.001), preoccupation with postpartum-specific intrusive thoughts (r = 0.32-0.45, p < 0.001), and preoccupation with neutralising strategies (r = 0.21-0.29, p < 0.05) at both time points. PTSD symptoms were also predictive of checking and obsessing symptoms. This study identified PTSD symptoms as a new correlate for preoccupation with postpartum-specific intrusive thoughts and neutralising strategies in the postpartum period in a community sample. These findings add to the evidence suggesting a strong association between PTSD and OCD symptoms across the lifespan, including in non-clinical samples. Future research should examine best practices to assess and treat a variety of postpartum psychopathology symptoms, not just depression.

Perinatal Posttraumatic Stress Disorder Diagnoses Among Commercially Insured People Increased, 2008-20

Posttraumatic stress disorder (PTSD) is a burdensome disorder, affecting 3-4 percent of delivering people in the US, with higher rates seen among Black and Hispanic people. The extent of clinical diagnosis remains unknown. We describe the temporal and racial and ethnic trends in perinatal PTSD diagnoses among commercially insured people with live-birth deliveries during the period 2008-20, using administrative claims from Optum's Clinformatics Data Mart Database. Predicted probabilities from our logistic regression analysis showed a 394 percent increase in perinatal PTSD diagnoses, from 37.7 per 10,000 deliveries in 2008 to 186.3 per 10,000 deliveries in 2020. White people had the highest diagnosis rate at all time points (208.0 per 10,000 deliveries in 2020), followed by Black people, people with unknown race, Hispanic people, and Asian people (188.7, 171.9, 146.9, and 79.8 per 10,000 deliveries in 2020, respectively). The significant growth in perinatal PTSD diagnosis rates may reflect increased awareness, diagnosis, or prevalence of the disorder. However, these rates fall well below the estimated prevalence of PTSD in the perinatal population.

Are midwives trained to recognise perinatal depression symptoms? Results of MAMA (MAternal Mood Assessment) cross-sectional survey in Italy

PURPOSE

To assess the knowledge, clinical experience, and attitudes of Italian midwives toward perinatal depression (PND) and to explore how these factors impact the quality of care.

METHODS

We conducted a cross-sectional online survey among 152 midwives employed in public hospitals across Italy. The questionnaire covered a range of topics, including demographic data, professional experience, knowledge of PND symptoms, risk factors, and clinical management, as well as communication skills and personal experiences with PND cases.

RESULTS

A concerning 76.3% of midwives displayed inadequate knowledge of PND based on current scientific literature. Those with a more comprehensive understanding were notably more confident in their practice, expressing significantly fewer apprehensions about communicating with mothers (25.8% vs 74.2%) and lesser concerns about the mothers' future well-being (38.9% vs 62.95%). The survey results also emphasised the midwives' call for specialised guidelines and formal training in PND management and underscored the value of communication skills, continuity of care, and family engagement in supporting affected mothers.

CONCLUSION

This inaugural study sheds light on the current state of knowledge and attitudes among Italian midwives regarding PND. It pinpoints crucial areas for educational enhancement and practice improvement, suggesting that elevated levels of midwife expertise in PND could significantly elevate the standard of care and expedite early diagnosis and treatment.

Global prevalence of perinatal depression and anxiety during the COVID-19 pandemic: An umbrella review and meta-analytic synthesis

INTRODUCTION

The prevalence of depression and anxiety symptoms in pregnant and postpartum women during the COVID-19 pandemic was assessed by several systematic reviews (SRs) and meta-analyses which provided contrasting and different results. We aimed to summarize the evidence relating to the global prevalence of anxiety and depression among pregnant and postpartum women during the COVID-19 pandemic.

MATERIAL AND METHODS

An umbrella review of SRs and meta-analyses was performed. Searches were conducted in electronic databases up to April 2023. SRs and meta-analyses reporting the prevalence of perinatal anxiety and depression during the COVID-19 pandemic were selected for eligibility. Primary studies extracted from eligible meta-analyses were included in the quantitative synthesis. The research protocol was registered on PROSPERO (CRD42020173125).

RESULTS

A total of 25 SRs (198 primary studies) and 12 meta-analyses (129 primary studies) were included in the qualitative and quantitative synthesis, respectively. Studies involved data from five continents and 45 countries. The pooled prevalence of antenatal and postpartum depression was 29% (n = 55; 95% CI: 25%-33%) and 26% (n = 54; 95% CI: 23%-30%), respectively. In the case of anxiety, the pooled antenatal and postnatal prevalence was 31% (n = 44; 95% CI: 26%-37%; n = 16; 95% CI: 24%-39%). Differences emerged between continents, with Africa having the highest prevalence of perinatal depression and Oceania and Europe having the highest prevalence of antenatal and postnatal anxiety. The prevalence also varied depending on the assessment tools, especially for antenatal anxiety. A medium-high quality of the studies was observed. One SR assessed strength-of-evidence, reporting very low strength.

CONCLUSIONS

During the COVID-19 pandemic, depression and anxiety were common, affecting almost one in three perinatal women globally. A high heterogeneity and a risk of publication bias were found, partially due to the variety of assessment tools and cut-offs. The results may not be generalized to minorities. Studies on the prevalence of clinical diagnoses are needed. Based on our results it is not possible to firmly affirm that the COVID-19 pandemic was the main factor that directly increased perinatal depression and anxiety during the past few years. Future studies should study other factors' impact.

Applications of dialectical behavioural therapy in the perinatal period: A scoping review

Psychological distress is the most common complication of pregnancy. High-risk concerns can include severe emotion dysregulation, suicidality and self-injury, and health risk behaviours, which bear substantial consequences for caregivers and families. Yet, effective, comprehensive interventions for high-risk caregivers have received limited attention. Dialectical behaviour therapy (DBT) is a frontline treatment for such concerns. Accordingly, we conducted a scoping review on the implementation of DBT in the perinatal period. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Seven studies were identified; study designs included case studies and single-arm pilot trials. Most studies used DBT-informed protocols with significant adaptations, few included multiple components of DBT (i.e. skills group, individual therapy, phone coaching and consultation team), and none met criteria for adherent delivery of all four modes of DBT treatment. Findings suggest DBT-informed interventions may be successfully implemented to treat a range of perinatal mental health symptoms, including borderline personality disorder, depression, anxiety, and post-traumatic stress, and to promote emotion regulation and positive parenting behaviours. While results provide preliminary support for perinatal DBT, this literature is scant and empirical rigour considerably lacking. Clinical implications and future directions are outlined to aid researchers and providers in addressing the ongoing perinatal mental health crisis and developing sorely needed interventions to address the needs of high-risk caregivers.

Successful Management and Birth After Perimortem Cesarean Delivery and Stillbirth Due to Anaphylaxis

Perimortem cesarean delivery is an effective procedure for cardiopulmonary resuscitation during pregnancy. However, there are no reports documenting long-term outcomes in perimortem cesarean delivery survivors. This may be the first report of a successful live birth, occurring two years after perimortem cesarean delivery. A 29-year-old primipara was transferred to the emergency center on account of cardiopulmonary arrest, at 33 weeks of gestation. She was resuscitated 47 min after cardiopulmonary arrest by perimortem cesarean delivery amongst other treatment modalities, although the fetus died. Two months later, she was discharged with a preserved uterus, and no neurological damage. The couple suffered from posttraumatic stress disorder, which they overcame with the support of the multidisciplinary team, then gave birth to a healthy baby 2 years later. To overcome cardiopulmonary arrest during pregnancy, a seamless approach by a multidisciplinary team is essential for a good patient outcome.

Association of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act on severe maternal morbidity

OBJECTIVE

This study aimed to characterize the association between Mental Health Parity and the Affordable Care Act and rates of severe maternal morbidity among a population of commercially insured individuals, including individuals with and without perinatal mood and anxiety disorders.

METHODS

We conducted a serial, cross-sectional analysis of individuals with an inpatient delivery in Optum's Clinformatics® Data Mart Database from 2008 to 2021. We applied an interrupted time series model with autoregressive integrated moving average to evaluate changes in quarterly severe maternal morbidity rates.

RESULTS

Adjusted severe maternal morbidity rates declined from 167.2 (95%CI: [152.6, 181.9]) per 10,000 deliveries in the first quarter of 2008 to 98.2 (95%CI: [83.5, 112.8]) per 10,000 deliveries in the last quarter of 2021. Severe maternal morbidity rates remained higher, but declined to a greater degree, among those with perinatal mood and anxiety disorders (435.6, 95%CI: [379.9, 491.3], to 165.0, 95%CI: [109.3, 220.8] per 10,000 deliveries) compared to those without (153.0, 95%CI: [140.7, 165.3] to 81.8, 95%CI: [69.6, 94.1] per 10,000 deliveries).

CONCLUSION

The observed association suggests implementation of Mental Health Parity and Affordable Care Act may have played a role in lowering rates of severe maternal morbidity, particularly among individuals with perinatal mood and anxiety disorders.

Maternal postpartum depression literacy subtypes: A latent profile analysis

Aim

To explore the potential categories and characteristic differences of maternal postpartum depression literacy.

Design

Cross-sectional survey.

Methods

From February 2023 to April 2023, convenience sampling was used to survey 278 women attending postnatal visits to three tertiary level A hospitals. The study included general demographic characteristics, postpartum depression literacy scale, and family caring index scale. Latent profile analysis was performed to identify the categories of maternal postpartum depression literacy, and multiple disordered logistic regression was used to analyze the influencing factors of different categories.

Results

Maternal postpartum depression literacy was divided into three categories: low literacy (41.0 %), moderate literacy (32.4 %), and high literacy (26.6 %). The results showed that work status, education level, whether the pregnancy was planned, whether or not they had participated in mental health-related courses, and family functioning status were factors influencing the category of maternal postpartum depression literacy (P < 0.05).

Conclusion

There was heterogeneity in postpartum depression literacy among mothers. Medical staff should implement targeted interventions according to potential category characteristics and influencing factors to improve the level of postpartum depression literacy.

Association of severe maternal morbidity with bonding impairment and self-harm ideation: A multicenter prospective cohort study

BACKGROUND

Evidence on the association between severe maternal morbidity (SMM) and mother-infant bonding and self-harm ideation is limited. We aimed to examine these associations and the mediating effect of Neonatal Intensive Care Unit (NICU) admission at one-month postpartum.

METHODS

This multicenter, prospective cohort study was conducted in Japan (n = 5398). SMM included preeclampsia, eclampsia, severe postpartum hemorrhage, placental abruption, and a ruptured uterus. Lack of affection (LA) and Anger and Rejection (AR) were assessed using the Mother-Infant Bonding Scale (MIBS), and self-harm ideation was assessed using the 10th item of the Edinburgh Postnatal Depression Scale (EPDS). Linear and logistic regression models were used to examine the association between SMM and MIBS score and self-harm ideation. A structural equation model (SEM) was employed to examine the mediating effect of NICU admission on the association between SMM and mother-infant bonding and postpartum depressive symptoms.

RESULTS

Women with SMM had a 0.21 (95 % confidence interval [CI]: 0.03-0.40) point higher MIBS score and a decreasing trend in the risk of self-harm ideation (odds ratio 0.28, 95 % CI: 0.07-1.14) compared to those without SMM. SEM analysis revealed that SMM was associated with MIBS partially through NICU admission.

LIMITATIONS

EPDS scores during pregnancy could be an unmeasured confounder.

CONCLUSIONS

Women with SMM had higher MIBS scores, particularly on the LA subscale, which was partially mediated by NICU admission. Psychotherapy to support parent-infant relationships is necessary for women with SMM.

Maternal n-3 PUFA Intake During Pregnancy and Perinatal Mental Health Problems: A Systematic Review of Recent Evidence

PURPOSE OF REVIEW

Pregnant women are vulnerable to mental health problems. Increasing evidence shows that omega-3 polyunsaturated fatty acid (n-3 PUFA) intake during pregnancy is beneficial to maternal perinatal mental health. A systematic review is needed to examine the associations reported in recent studies. The objective of this review was to provide an updated review on the association of antenatal n-3 PUFA intake via different sources (seafood, fish, overall diet, and supplementation) with perinatal mental health problems including depression, anxiety, and psychological distress.

RECENT FINDINGS

Searches were performed in Web of Science, Embase, PubMed, and APA PsycInfo databases on 21 June 2021. A total of 2133 records were screened. Data including the name of the first author, publication year, study design, sample characteristics, dietary assessment time and tools, mental health outcome measures, and other relevant information were extracted. In total, 13 articles were included in this review and assessed qualitatively. The results demonstrated that dietary intake of n-3 PUFA during pregnancy was associated with perinatal mental health, but the effect of n-3 PUFA supplementation was influenced by pre-existing medical conditions, socio-demographic characteristics, and dietary and lifestyle patterns during pregnancy. Our review found that sources of n-3 PUFA may have differential effects on woman's mental health during and after pregnancy. Further research using large-size cohort or well-controlled trial protocol is needed to determine the effect of n-3 PUFA supplementation during pregnancy on perinatal mental health.

Mind Matters: A Critical Look at Malaysia's Postnatal Depression Policy for Women's Mental Health

Introduction

This policy brief examines the national health and action plans, laws and regulations, public health policies, and clinical practice guidelines in Malaysia on postnatal depression (PND).

Methods

We examined and included 13 documents for the presence or lack of a statement of intent and/or actions related to caring for women at risk for or experiencing PND.

Results

Although PND is actively researched and included in the clinical practice guidelines, no other policy documents mention PND.

Conclusion

General recommendations to address this matter include channeling resources into developing care for PND, increasing advocacy work to reduce stigma, setting up appropriate training pathways for health care providers, and creating more roles and user-friendly modules for local volunteers to deliver mental health interventions.

Burden of mental health problems among pregnant and postpartum women in sub-Saharan Africa: systematic review and meta-analysis protocol

INTRODUCTION

Pregnancy and postpartum-related mental health problems pose serious public health threat to the society, but worryingly, neglected in sub-Saharan Africa (SSA). This review will assess the burden and distribution of maternal mental health (MMH) problems in SSA, with the aim to inform the implementation of context sensitive interventions and policies.

METHODS AND ANALYSIS

All relevant databases, grey literature and non-database sources will be searched. PubMed, LILAC, CINAHL, SCOPUS and PsycINFO, Google Scholar, African Index Medicus, HINARI, African Journals Online and IMSEAR will be searched from inception to 31 May 2023, without language restriction. The reference lists of articles will be reviewed, and experts contacted for additional studies missed by our searches. Study selection, data extraction and risk of bias assessment will be done independently by at least two reviewers and any discrepancies will be resolved through discussion between the reviewers. Binary outcomes (prevalence and incidence) of MMH problems will be assessed using pooled proportions, OR or risk ratio and mean difference for continuous outcomes; all will be presented with their 95% CIs. Heterogeneity will be investigated graphically for overlapping CIs and statistically using the I² statistic and where necessary subgroup analyses will be performed. Random-effects model meta-analysis will be conducted when heterogeneity is appreciable, otherwise fixed-effect model will be used. The overall level of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

Although no ethical clearance or exemption is needed for a systematic review, this review is part of a larger study on maternal mental health which has received ethical clearance from the Ethics Review Committee of the Ghana Health Service (GHS-ERC 012/03/20). Findings of this study will be disseminated through stakeholder forums, conferences and peer review publications.

PROSPERO REGISTRATION NUMBER

CRD42021269528.

Multiple pregnancy as a potential risk factor for postpartum depression: The Japan Environment and Children's Study

BACKGROUND

Postpartum depression (PPD) results in adverse consequences for both mother and infant. However, the association between multiple pregnancy and PPD is unknown because of the difference in the estimated prevalence rate of PPD based on country, ethnicity, and study type. Thus, this study aimed to determine whether Japanese women with multiple pregnancy were at a high risk of developing PPD at 1 and 6 months postpartum.

METHODS

In this nationwide prospective cohort study (the Japan Environment and Children's Study), conducted between January 2011 and March 2014, 77,419 pregnant women were enrolled. PPD was assessed using the Edinburgh Postnatal Depression Scale (EPDS) 1 and 6 months postpartum. A score of ≥13 points implied "positive" for PPD. Multiple logistic regression analyses estimated the association between multiple pregnancy and PPD risk.

RESULTS

Overall, 77,419 pregnancies (singleton, n = 76,738; twins, n = 676; triplets, n = 5) were included; 3.6 % and 2.9 % of pregnant women had PPD at 1 and 6 months postpartum, respectively. Compared with singleton pregnancy, multiple pregnancy was not associated with PPD at 1 month, but at 6 months postpartum (adjusted odd ratios: 0.968 [95 % confidence interval {CI}, 0.633-1.481] and 1.554 [95 % CI, 1.046-2.308], respectively).

LIMITATIONS

1) Some potential PPD risk factors could not be evaluated, 2) PPD was not diagnosed by psychiatrists, and 3) depressive symptoms at 6 months postpartum were considered PPD; however, definitions may vary.

CONCLUSIONS

Japanese women with multiple pregnancy may be regarded as a target group for follow-up and postpartum depression screening for at least 6 months during the initial postpartum period.

Inpatient obstetric consultation-liaison services: Meeting unmet needs in perinatal mental health

Obstetric patients are at increased risk for psychological distress and the development or exacerbation of mental illness, particularly in the setting of pregnancy or delivery complications. Inpatient antepartum, labor and delivery, and postpartum hospitalization is an important opportunity for psychiatric support and intervention. The aims of this paper are to review the unmet mental health needs in obstetric inpatient care, examine the current state of obstetric consultation-liaison (OB CL) psychiatry services, present one existing model of such a service at the authors' institution, provide broad recommendations for the structure and implementation of this service, and detail areas of future research within the area of OB CL psychiatry. We argue that the inpatient obstetric setting is a critical space for mental health evaluation, education and intervention, and that dedicated OB CL psychiatry services are a potentially valuable tool in addressing the perinatal mental health crisis.

Epidemiological profile of perinatal mental disorders at a tertiary hospital in Yaoundé- Cameroon

In developing countries, 15.6% of pregnant women and 19.8% after childbirth experience a mental disorder. In the absence of data on the situation in Cameroon, we carried out a study to determine the prevalence of perinatal mental illness in this hospital and its risk factors among women in perinatal period and the relationship between both at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, a reference mother and child hospital. We conducted a hospital-based, cross sectional, observational study. Data was collected using structured and semi-structured interviews. There were six sub-themes covered: participants' socio-demographic profile, clinical profile, perinatal history, psychopathology aspects with the Mini International Psychiatric Interview, the Edinburgh Postnatal Depression Scale, the State Trait Anxiety Inventory and the perinatal mental illness risk factors. Data entry was done using Microsoft Excel 2010 and transferred to Statistical Package for the Social Sciences version 23.0 for analysis. Among 194 women who participated in the study, the general prevalence for perinatal mental disorders was 53.6% (104/194), 25.8% among pregnant women and 27.8% among postnatal women. Comorbidities were present in 17.5% of our study population. We observed that 45.8% suffered from depression, 17% had a risk of suicide, 10.3% suffered from perinatal anxiety, 3.1% presented with post-traumatic stress disorder, 3.6% acute stress disorder, 7.7% had adjustment disorder. Concerning risk factors, we found a significant link between depression and severe anxiety before delivery (p < 0.05) and the absence of social support (p = 0.005). We found that women with at least four risk factors were 1.6 times more likely to present with a perinatal mental disorder. The prevalence of perinatal mental disorders at this Hospital is very high. This highlights the need for institutional screening and management of perinatal mental disorders, which suggests that we explore the situation in others and other health facilities in Cameroon.

The Time is Now: An Overview on Perinatal Psychiatry

Perinatal mental health (PMH) has been a growing field of practice for psychiatry in the last decades. It focuses on mental health during pregnancy, childbirth and the postpartum period including the distinctive presentations of mental illness and well‐being challenges associated with parenting experiences. Mental health problems in pregnancy and the postnatal period can have significant differences and challenges to its approach compared to other periods of life. Working in PMH requires specific and updated know­ ‐ledge regarding carers’ experiences and manifestations of mental illness in this particular life stage and psychotropic management during pregnancy and breastfeeding, as well as regarding the mother/parent and baby relationship and bond, and the baby’s safeguarding along several developmental issues. For all this, PMH specialist services and multidisciplinary teams with specific training have been developing to cater to this need in several countries around the world. To provide a broadened overlook on the matter, some key aspects of PMH will be discussed below in this perspective.

Trajectories of Postpartum Recovery: What is Known and Not Known

Women's postpartum health is a public health issue that has lifelong consequences. Timely recognition and treatment of physical and mental health issues can have positive health consequences while lack of access to effective treatments or health care services can lead to long-term health problems. To advance knowledge of priority health symptoms and trajectories of postpartum recovery from women's health perspectives, we share findings from the Maternal health And Maternal Morbidity in Ireland (MAMMI) study. Data from 3047 first-time mothers recruited to a longitudinal maternal health study in Ireland from 2012 to 2017 reveal the trajectories of maternal health and health problems experienced up to 12 months postpartum. Morbidities explored include urinary incontinence, pelvic girdle pain, and sexual and mental health issues. Viewed together, and over time, the scale and persistent nature of many physical and mental health problems become apparent, yet considerable proportions of women were not asked directly about health problems by health care professionals. When women do not know what is and is not normal postpartum, they may suffer in silence and the consequence is that health problems/issues that are preventable, and treatable, are likely to become chronic. To make positive contributions to women's health, maternity care systems must be truly woman-centered and structured in ways that place emphasis on women's own health needs. In systems where women's voices and concerns are acknowledged and central, women are likely to thrive and flourish in motherhood.

Efficacy and Safety of Transcranial Electric Stimulation during the Perinatal Period: A Systematic Literature Review and Three Case Reports

Introduction: The perinatal period is an at-risk period for the emergence or decompensation of psychiatric disorders. Transcranial electrical stimulation (tES) is an effective and safe treatment for many psychiatric disorders. Given the reluctance to use pharmacological treatments during pregnancy or breastfeeding, tES may be an interesting treatment to consider. Our study aims to evaluate the efficacy and safety of tES in the perinatal period through a systematic literature review followed by three original case reports. Method: Following PRISMA guidelines, a systematic review of MEDLINE and ScienceDirect was undertaken to identify studies on tES on women during the perinatal period. The initial research was conducted until 31 December 2021 and search terms included: tDCS, transcranial direct current stimulation, tACS, transcranial alternating current stimulation, tRNS, transcranial random noise stimulation, pregnancy, perinatal, postnatal, and postpartum. Results: Seven studies reporting on 33 women during the perinatal period met the eligibility criteria. No serious adverse effects for the mother or child were reported. Data were limited to the use of tES during pregnancy in patients with schizophrenia or unipolar depression. In addition, we reported three original case reports illustrating the efficacy and safety of tDCS: in a pregnant woman with bipolar depression, in a pregnant woman with post-traumatic stress disorder (sham tDCS), and in a breastfeeding woman with postpartum depression. Conclusions: The results are encouraging, making tES a potentially safe and effective treatment in the perinatal period. Larger studies are needed to confirm these initial results, and any adverse effects on the mother or child should be reported. In addition, research perspectives on the medico-economic benefits of tES, and its realization at home, are to be investigated in the future.

Characteristics and co-admissions of mothers and babies admitted to residential parenting services in the year following birth in NSW: a linked population data study (2000-2012)

Background

There is a tiered healthcare system in Australia to support maternal and child health, including, non-psychiatric day stay and residential parenting services (RPS) such as Tresillian and Karitane (in New South Wales [NSW]). RPS are unique to Australia, and currently there is limited information regarding the healthcare trajectory of women accessing RPS and if they are more likely to have admissions to other health facilities within the first-year post-birth. This study aimed to examine differences in hospital co-admissions for women and babies admitted to RPS in NSW in the year following birth compared to non-RPS admitted women.

Methods

A linked population data study of all women giving birth in NSW 2000–2012. Statistical differences were calculated using chi-square and student t-tests.

Results

Over the 12-year timeframe, 32,071 women and 33,035 babies were admitted to RPS, with 5191 of these women also having one or more hospital admissions (7607 admissions). The comparator group comprised of 99,242 women not admitted to RPS but having hospital admissions over the same timeframe (136,771 admissions). Statistically significant differences between cohorts were observed for the following parameters (p ≤ .001). Based upon calculated percentages, women who were admitted to RPS were more often older, Australian born, socially advantaged, private patients, and having their first baby. RPS admitted women also had more multiple births and labour and birth interventions (induction, instrumental birth, caesarean section, epidural, episiotomy). Their infants were also more often male and admitted to Special Care Nursery/Neonatal Intensive Care. Additionally, RPS admitted women had more admissions for mental health and behavioural disorders, which appeared to increase over time. There was no statistical difference between cohorts regarding the number of women admitted to a psychiatric facility; however, women attending RPS were more likely to have mood affective, or behavioural and personality disorder diagnoses.

Conclusion

Women accessing RPS in the year post-birth were more socially advantaged, had higher birth intervention and more co-admissions and treatment for mental health disorders than those not accessing RPS. More research is needed into the impact of birth intervention and mental health issues on subsequent parenting difficulties.

LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review

BACKGROUND

The perinatal period may uniquely impact the mental health and wellbeing of lesbian, gay, bisexual, transgender, queer, and Two-Spirit (LGBTQ2S+) childbearing individuals.

OBJECTIVES

To characterise and synthesise the experiences of LGBTQ2S+ childbearing individuals regarding perinatal mental health, including symptomatology, access to care and care-seeking.

SEARCH STRATEGY

We conducted and reported a systematic review following PRISMA guidelines of eight databases (EMBASE, MEDLINE-OVID, CINAHL, Scopus, Web of Science: Core Collection, Sociological Abstracts, Social Work Abstract, and PsycINFO) from inception to 1 March 2021.

SELECTION CRITERIA

Original, peer-reviewed research related to LGBTQ2S+ mental health was eligible for inclusion if the study was specific to the perinatal period (defined as pregnancy planning, conception, pregnancy, childbirth, and first year postpartum; includes miscarriages, fertility treatments and surrogacy).

DATA COLLECTION AND ANALYSIS

Findings were synthesised qualitatively via meta-aggregation using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), and the ConQual approach.

MAIN RESULTS

Our systematic search included 26 eligible studies encompassing 1199 LGBTQ2S+ childbearing participants. Using the JBI SUMARI approach, we reported 65 results, which we synthesised as six key findings. The studies described unique considerations for LGBTQ2S+ individuals' perinatal mental health, including heteronormativity, cisnormativity, isolation, exclusion from traditional pregnancy care, stigma, and distressing situations from the gendered nature of pregnancy. Many participants described a lack of knowledge from healthcare providers related to care for LGBTQ2S+ individuals. In addition, LGBTQ2S+ individuals described barriers to accessing mental healthcare and gaps in health systems. Strategies to improve care include provider education, avoidance of gendered language, documentation of correct pronouns, trauma-informed practices, cultural humility training and tailored care for LGBTQ2S+ people.

CONCLUSIONS

Pregnancy, postpartum, and the perinatal period uniquely impacts the mental health and wellbeing of LGBTQ2S+individuals, largely due to systems-level inequities and exclusion from perinatal care. Healthcare providers should implement the identified strategies to improve perinatal care and address inequities.

The impact of postpartum obsessive-compulsive symptoms on child development and the mediating role of the parent-child relationship: A prospective longitudinal study

BACKGROUND

The first 2 years of life are a particularly sensitive period for the parent-child relationship as well as a healthy, age-appropriate child development. Both have been shown to be linked to postpartum depressive and anxiety symptoms, while the role of obsessive-compulsive symptoms, which are also common, is still largely understudied. In addition, fathers have been neglected in this area of research. This study, which includes both mothers and fathers, aims to investigate the longitudinal associations between postpartum obsessive-compulsive symptoms and different domains of child development, as well as the mediating role of the parent-child relationship.

METHODS

Data were drawn from the prospective longitudinal study DREAM, with 674 mothers and 442 fathers from the general population completing self-report questionnaires at four measurement points. Longitudinal associations between parental postpartum obsessive-compulsive symptoms 8 weeks postpartum, the parent-child relationship 14 months postpartum, and child development 24 months postpartum were investigated using regression and mediation analyses. A number of potential confounding variables were considered, i.e., age, academic degree, postpartum depressive and anxiety symptoms of the parents, preterm birth and temperament of the child, as well as COVID-19 pandemic-driven adversities.

RESULTS

When adjusting for confounders, neither maternal nor paternal postpartum obsessive-compulsive symptoms had adverse effects on the respective parent-child relationship and child development. Further, no mediating role of the parent-child relationship between parental postpartum obsessive-compulsive symptoms and child development could be confirmed. Instead, we found that the mother- and father-child relationship were differentially related to specific child developmental domains. For mothers, a poorer mother-child relationship was prospectively related to poorer fine motor development. For fathers, a poorer father-child relationship prospectively predicted a poorer overall development as well as poorer gross motor, fine motor, problem-solving, and personal-social development.

CONCLUSION

Our results suggest that negative effects on the parent-child relationship and child development may only become apparent in full-blown postpartum obsessive-compulsive disorder. Given the differential impact on specific developmental domains, our findings also suggest that it is crucial to consider both parents in clinical practice as well as in future research, rather than focusing only on the mother-child dyad.

Maternal mental health in the first year postpartum in a large Irish population cohort: the MAMMI study

PURPOSE

The international perinatal literature focuses on depression in the postpartum period. Prevalence and pathways of depression, anxiety and stress from pregnancy through the first postpartum year are seldom investigated.

METHODS

MAMMI is a prospective cohort study of 3009 first-time mothers recruited in pregnancy. Depressive, anxiety and stress symptoms measured using the Depression, Anxiety and Stress Scale (DASS 21) in pregnancy and at 3-, 6-, 9- and/or 12-months postpartum.

RESULTS

Prevalence of depressive and stress symptoms was lowest in pregnancy, increasing to 12-months postpartum. Anxiety symptoms remained relatively stable over time. In the first year after having their first baby, one in ten women reported moderate/severe anxiety symptoms (9.5%), 14.2% reported depression symptoms, and one in five stress symptoms (19.2%). Sociodemographic factors associated with increased odds of postpartum depression, anxiety and stress symptoms were younger age and being born in a non-EU country; socioeconomic factors were not living with a partner, not having postgraduate education and being unemployed during pregnancy. Retrospective reporting of poor mental health in the year prior to pregnancy and symptoms during pregnancy were strongly associated with poor postpartum mental health.

CONCLUSIONS

The current findings suggest that the current model of 6-week postpartum care in Ireland is insufficient to detect and provide adequate support for women's mental health needs, with long-term implications for women and children.

The role of the immune system in postpartum psychosis

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. The risk is particularly high for women with a history of bipolar disorder or schizoaffective disorder, or those who have suffered a previous episode of postpartum psychosis. However, the aetiology of the illness remains unclear. Pregnancy and the early postpartum are times of significant immunological change. Furthermore, alterations to the immune system have been implicated in the onset and course of various psychopathologies, both related and unrelated to childbirth. Emerging evidence, from studies on immune related disorders, immune cells and inflammatory markers, suggests that the immune system might also be involved in the pathophysiology of postpartum psychosis. Furthermore, recent research has also begun to explore the potential mechanisms underlying immune dysfunction in postpartum psychosis (e.g., disturbances in the Treg-CCN3 protein-(re)myelination axis). Nevertheless, more research is required to understand whether immune dysfunction is a cause or consequence of postpartum psychosis and to clarify the exact mechanisms involved. The aim of this short review is to present the current findings on immune system dysregulation in postpartum psychosis, discuss possible mechanisms underlying the association, highlight potential challenges and confounders and provide suggestions for future research.

The favourable association of self-reported physical fitness with depression and anxiety during pregnancy. The GESTAFIT project

We explored the association of self-reported physical fitness with depressive symptoms and anxiety levels during pregnancy. One hundred fifty-five pregnant women (32.9 ± 4.7 years old) participated in the study. Self-reported physical fitness was assessed with the International Fitness Scale, depressive symptoms and state anxiety levels with the Center for Epidemiological Studies-Depression Scale and the State Trait Anxiety Index, respectively, at the 16 and 34 weeks of gestation. In model 1 (adjusted for age and gestational weight gain), greater overall self-reported physical fitness was associated with fewer depressive symptoms at the 16 weeks (p = .004). Greater self-reported cardiorespiratory fitness and muscular strength were associated with lower anxiety levels at the 16 weeks (all, p > .05). Greater overall self-reported physical fitness, cardiorespiratory fitness and speed-agility were associated with lower anxiety levels at the 34 weeks (all, p > .05). These results were also confirmed in model 2 (additionally adjusted for the exercise intervention, sleep quality, educational level, working status and cohabitating), except for cardiorespiratory fitness and anxiety levels at the 16 weeks (p = .09). Greater self-reported physical fitness was associated with lower psychological ill-being during pregnancy. Specifically, at the 16 weeks, greater self-reported overall physical fitness was associated with fewer depressive symptoms, greater self-reported muscular strength with lower anxiety levels; greater self-reported overall physical fitness and speed-agility with lower anxiety levels at the 34 weeks and greater self-reported cardiorespiratory fitness with lower anxiety levels during the pregnancy. Screening of physical fitness may reduce the risk of depression and anxiety and generally improve pregnancy mental health-related quality of life.HighlightsMaternal depression and anxiety have prevalence rates between 8 and 36%.Physical fitness enhancement during pregnancy results in less depression and anxiety.Greater physical fitness may provide benefits for the mother mental health.Self-reported physical fitness screening during pregnancy may be useful in clinical settings.

Predictors of fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Pwani region, Tanzania

BACKGROUND

Many women experience fear of childbirth (FoB) and depressive symptoms (DS) during pregnancy, but little is known about FoB among Tanzanian women. The current study aimed to assess the prevalence of FoB and DS among pregnant women and determine predictors of each and both, focusing on sociodemographic and obstetric predictors.

METHODS

A cross-sectional study was conducted at six health facilities in two districts in Tanzania between 2018 and 2019. In total, 694 pregnant women with gestational age between 32 and 40 weeks and expecting vaginal delivery were consecutively recruited and assessed for FoB and DS. We collected data through interviews using 6 and 4-points Likert Scale of the Wijma Delivery Expectancy Questionnaire Version A and Edinburgh Postnatal Depression Scale, respectively. Women who scored ≥66 and ≥ 10 were categorised as having FoB and DS, respectively. We performed multivariable logistic regression to investigate the predictors of FoB and DS.

RESULTS

The prevalence rates of FoB and DS among pregnant women were 15.1 and 17.7%, respectively. FoB and DS were more likely in women aged above 30 years [Adjusted Odds Ratio (AOR) 6.29, 95%CI 1.43-27.84] and in single mothers (AOR 2.57, 95%CI 1.14-5.78). Women with secondary education and above (AOR 0.22, 95%CI 0.05-0.99) and those who had given birth previously (AOR 0.27, 95% CI 0.09-0.87) were less likely to have FoB in combination with DS Women who had previous obstetric complications, and those who did not receive any social support from male partners in previous childbirth were more likely to have FoB and DS. FoB was strongly associated with DS (AOR 3.42, 95%CI 2.12-5.53). DS only was more common in women who had inadequate income (AOR 2.35, 95%CI 1.38-3.99) or had previously experienced a perineal tear (AOR 2.32, 95%CI 1.31-4.08).

CONCLUSIONS

Not having a formal education, having only primary education, being aged above 30 years, being single, being nulliparous, having experienced obstetric complications, and having a lack of social support from a male partner during previous pregnancy and childbirth were predictors of FoB and DS during pregnancy. FoB and DS were strongly associated with each other. It is vital to identify at-risk women early, to offer support during pregnancy and childbirth.

Symmetry in Paraspinal Muscles as a Predictor of the Development of Pregnancy-Related Low Back and Pelvic Pain: A Prospective Study

Objective

To determine the asymmetry in the paraspinal muscle before pregnancy and evaluate its association with pregnancy‐associated lumbopelvic pain (LPP).

Methods

This was a prospective case–control study conducted from January 2017 and December 2018. A total of 171 subjects (mean age ± SD, 27.4 ± 5.8 years) were finally divided into the LBP group, PGP group, and no LPP group. Each subject was asked to follow a standardized clinical imaging protocol before the pregnancy. The area of muscles (multifidus, erector spinae, and psoas muscles) on the axial slice at mid‐disc of L₄–L₅ and L₅–S₁ were segmented and then the cross‐sectional area (CSA) of a particular muscle was measured by outlining the innermost fascial border surrounding each muscle. The mean value of F‐CSA's ratio to T‐CSA (F/T CSA) was used to determine whether the bilateral paraspinal muscle was asymmetrical. Total muscle CSA (T‐CSA) represents the sum of CSA of interested three muscles. The signal intensity can distinguish fat and muscle tissue in a different range. Based on this, functional CSA (F‐CSA), represented by fat‐free area, was evaluated quantitively by excluding the signal of the deposits of intramuscular fat. Total muscle CSA (T‐CSA), functional CSA (F‐CSA), and the ratio of F‐CSA to T‐CSA (F/T CSA) were measured unilaterally and compared between groups. Logistic regression was performed to determine the risk factors for pregnancy‐associated LPP. The Pearson correlation coefficient was performed to test the relationship between asymmetry in F/T‐CSA and pain rating.

Results

A total of 124 subjects (72.5%) (28.5 ± 5.2 years) had LPP during pregnancy. Forty‐eight (38.7%) individuals had low back pain (LBP) and 76 (61.3%) had pelvic girdle pain (PGP). Seventy‐six women (44.4%) were determined to have asymmetry in paraspinal muscle according to the definition in this methods section. The duration of follow‐up was 24 months postpartum. A total of 39 (31.5%) women unrecovered from LPP. F/T‐CSA was significantly decreased for LBP in the PGP group than in the and control group (0.03 ± 0.02 vs 0.05 ± 0.03 vs 0.12 ± 0.05, P < 0.001). Meanwhile, significant differences were detected in both groups (all P < 0.001). In patients with LBP, the level of paraspinal asymmetry, represented by the difference in F/T‐CSA, was positively correlated with pain scores (r = 0.52, P < 0.01). However, no statistically significant correlation between pain scores and paraspinal asymmetry was found in PGP (r = 0.42, P > 0.05). Asymmetry in the paraspinal muscle (adjusted OR = 1.5), LBP (adjusted OR = 1.6), LPP in a previous pregnancy (adjusted OR = 1.4), sick leave ≥90 days (adjusted OR = 1.2), and heavy labor (adjusted OR = 1.2) were risk factors for the unrecovered LPP during pregnancy.

Conclusions

Asymmetrical muscular compositions could lead to abnormal biomechanics for the segmental motions. Lateral‐directed physical training and stretching may help decrease the occurrence and severity of this condition.

Prenatal electrocardiogram testing and postpartum depression: A population-based cohort study

Background

Cardiovascular symptoms in pregnancy may be a clue to psychological distress. We examined whether electrocardiogram testing in pregnant women is associated with an increased risk of subsequent postpartum depression.

Methods

We conducted a population-based cohort study of pregnant women who delivered in Ontario, Canada comparing women who received a prenatal ECG to women who did not.

Results

In total, 3,238,218 women gave birth during the 25-year study period of whom 157,352 (5%) received an electrocardiogram during prenatal care. Receiving an electrocardiogram test was associated with a one-third relative increase in the odds of postpartum depression (odds ratio 1.34; 95% confidence interval 1.29–1.39, p < 0.001).

Conclusion

The association between prenatal electrocardiogram testing and postpartum depression suggests a possible link of organic disease with mental illness, and emphasizes that cardiovascular symptoms may be a clinical clue to the presence of an underlying mood disorder.

Personality traits predict regression of pelvic girdle pain after pregnancy: a longitudinal follow-up study

Background

Pelvic girdle pain (PGP) is a multifactorial condition with a partly unknown etiology. This condition can be mentally and physically compromising both during and after pregnancy. To provide all-around preventive measures to improve the recovery from PGP, it is a necessity for obstetricians and orthopaedists to develop predictive studies about the worse prognosis for this condition. Therefore, this study aims to determine whether personality traits can predict the consequences of long-term pregnancy-related PGP.

Methods

This was a prospective study conducted from January 2015 to August 2018. A total of 387 pregnant women were enrolled in this study. According to whether they had experienced PGP during the past 4 weeks, the subjects were classified into no PGP and PGP groups. Persistent PGP after the pregnancy was defined as a recurrent or continuous visual analog score (VAS) pain rating of ≥3 for more than 1 week. The Quick Big Five Personality Test (QBFPT) was used to assess personality traits. Data were obtained by mail or in the clinic. The authors collected data including age, BMI, educational level, annual household income, cesarean delivery, breastfeeding, unexpected sex of the baby, parity, sick leave, no or rare ability to take rest breaks at work, and PGP in the previous pregnancy.

Results

Of 387 included women, 264 subjects experienced PGP during the pregnancy with a mean age of 26.3 ± 4.5 years. A total of 80 of 264 (30.3%) women experienced persistent PGP after the pregnancy. Persistent PGP after the pregnancy was associated with higher levels of neuroticism (OR = 2.12, P = 0.001). Comparing women with persistent PGP, those who reported higher levels of extraversion and conscientiousness were more likely to recover from this condition (OR = 0.65, P = 0.001; OR = 0.78, P = 0.010, respectively). Besides, neuroticism was positively associated with higher pain scores (r = 0.52, P = 0.005). However, extraversion and conscientiousness domains showed negative correlations with pain score (r = − 0.48, P = 0.003; r = − 0.36, P = 0.001).

Conclusions

Personality traits were significantly associated with the outcomes of PGP.

Association between the serum insulin-like growth factor-1 concentration in the first trimester of pregnancy and postpartum depression

AIM

Patients with major depression present with an increased serum insulin-like growth factor-1 (IGF-1) concentration. However, the longitudinal relationship between serum IGF-1 levels and depression development remains unclear. This study aimed to investigate the longitudinal association between the serum IGF-1 concentration in the first trimester of pregnancy and postpartum depression development using data obtained from the Japan Environment and Children's Study (JECS).

METHODS

The JECS included 97 415 pregnant women; among them, 8791 were enrolled in this study. Data regarding depression in the first trimester, postpartum depression development at 1 month after childbirth, and other covariates were collected using a self-administered questionnaire. Serum IGF-1 levels were measured in the first trimester of pregnancy. The participants were divided into four groups according to the serum IGF-1 level.

RESULTS

In the first trimester, serum IGF-1 levels were not significantly associated with psychological distress in pregnant women. In the longitudinal analyses, however, postpartum depression development in mothers within the highest quartile for serum IGF-1 concentration in the first trimester was significantly less common than in those within the lowest quartile (odds ratio 0.48, 95% confidence interval 0.30-0.79).

CONCLUSION

Pregnant women with a high serum IGF-1 concentration in the first trimester were less likely to develop postpartum depression than those with a low concentration. A high serum IGF-1 concentration during pregnancy may help to protect against postpartum depression development.

Mapping of Transdiagnostic Neuropsychiatric Phenotypes Across Patients in Two General Hospitals

BACKGROUND

Multidimensional transdiagnostic phenotyping systems are increasingly important to neuropsychiatric phenotyping, particularly in translational research settings. The relationship the National Institute of Mental Health's Research Domain Criteria multidimensional approach to psychopathology and nonpsychiatric diagnoses has not been studied at scale but is relevant to those caring for neuropsychiatric illness in medical and surgical settings.

METHODS

We applied the CQH Dimensional Phenotyper natural language processing tool to estimate National Institute of Mental Health's Research Domain Criteria domain-associated symptoms of individuals admitted to nonpsychiatric wards at each of 2 large academic general hospitals over an 8-year period. We compared patterns in individual domain symptom burden, as well as a new pooled unidimensional measure, by primary medical and surgical diagnosis.

RESULTS

Analysis included 227,243 patients from hospital 1 of whom 68,793 (30.3%) had a prior psychiatric history and 220,213 patients from hospital 2 of whom 50,818 (23.1%) had a prior psychiatric history. The distribution of Research Domain Criteria symptom burdens over primary diagnosis was similar across hospital sites and differed significantly across primary medical or surgical diagnosis. The effect of primary medical or surgical diagnosis was larger than that of prior psychiatric history on Research Domain Criteria symptom burden.

CONCLUSION

Research Domain Criteria-based neuropsychiatric symptom burden estimated from general hospital patients' clinical documentation is more strongly associated with the primary hospital medical or surgical diagnosis than it is with the presence of a previous psychiatric history. The bidirectional role of psychiatric and somatic illness warrants further study through the lens of transdiagnostic phenotyping.

Examining the association between family status and depression in the UK Biobank

BACKGROUND

We examined associations between family status (living with a spouse or partner and number of children) and lifetime depression.

METHODS

We used data from the UK Biobank, a large prospective study of middle-aged and older adults. Lifetime depression was assessed as part of a follow-up mental health questionnaire. Logistic regression was used to estimate associations between family status and depression. We included extensive adjustment for social, demographic and other potential confounders, including depression polygenic risk scores.

RESULTS

52,078 participants (mean age = 63.6, SD = 7.6; 52% female) were included in our analyses. Living with a spouse or partner was associated with substantially lower odds of lifetime depression (OR = 0.67, 95% CI 0.62-0.74). Compared to individuals without children, we found higher odds of lifetime depression for parents of one child (OR = 1.17, 95% CI 1.07-1.27) and parents of three (OR = 1.11, 95% CI 1.03-1.20) or four or more children (OR = 1.27, 95% CI 1.14-1.42). Amongst those not cohabiting, having any number of children was associated with higher odds of lifetime depression. Our results were consistent across age groups, the sexes, neighbourhood deprivation and genetic risk for depression. Exploratory Mendelian randomisation analyses suggested a causal effect of number of children on lifetime depression.

LIMITATIONS

Our data did not allow distinguishing between non-marital and marital cohabitation. Results may not generalise to all ages or populations.

CONCLUSIONS

Living with a spouse or partner was strongly associated with reduced odds of depression. Having one or three or more children was associated with increased odds of depression, especially in individuals not living with a spouse or partner.

Maternal dietary patterns and depressive symptoms during pregnancy: The Born in Guangzhou Cohort Study

BACKGROUND & AIMS

Maternal depression has been reported to be harmful to maternal and child health, and nutrition-mental health interactions may play a key role, but evidence from longitudinal studies throughout pregnancy remains insufficient. This study aimed to investigate the association of maternal dietary patterns with depressive symptoms throughout pregnancy.

METHODS

This study was based in the Born in Guangzhou Cohort Study. Dietary patterns were defined by cluster analysis based on validated food frequency questionnaires in mid-pregnancy. A healthy diet score was also developed based on predefined criteria of existing dietary guidelines. Depressive symptoms were measured by Self-rating Depression Scale (SDS) in both early and late pregnancy, with SDS scores ≥53 defined as having depressive symptoms. Associations of dietary patterns with SDS scores were examined by linear-mixed models; associations of dietary patterns with the odds of having depressive symptoms were examined by mixed-effects logistic models. The associations of the healthy diet score with both dietary patterns and depressive symptoms were also explored.

RESULTS

Six dietary patterns were identified in 17,430 pregnant women, namely 'Varied' (n = 3902, 22.4%), 'Vegetables' (n = 3269, 18.8%), 'Meats' (n = 2951, 16.9%), 'Cereals' (n = 2719, 15.6%), 'Milk' (n = 2377, 13.6%), and 'Fruits' (n = 2212, 12.7%). There were 19.3% and 15.7% of participants with depressive symptoms in early and late pregnancy, respectively. Compared with the 'Varied' pattern, all other patterns were associated with lower SDS scores during pregnancy except for 'Cereals' ('Vegetables': adjusted β [aβ] -0.78, 95% CI -1.16, -0.40; 'Meats': aβ -0.48, 95% CI -0.87, -0.09; 'Milk': aβ -0.52, 95% CI -0.94, -0.10; 'Fruits': aβ -0.85, 95% CI -1.27, -0.42). The 'Vegetables' (adjusted OR [aOR] 0.79, 95% CI 0.67, 0.93), 'Milk' (aOR 0.76, 95% CI 0.63, 0.91), and 'Fruits' (aOR 0.77, 95% CI 0.64, 0.93) patterns were associated with lower odds of having depressive symptoms during pregnancy than the 'Varied' pattern. Results for the healthy diet score revealed the healthiness of the 'Vegetables', 'Fruits', and 'Milk' patterns and supported an inverse association between healthy dietary patterns and depressive symptoms throughout pregnancy.

CONCLUSIONS

Diets rich in vegetables, fruits, nuts, and dairy products had an inverse association with depressive symptoms throughout pregnancy. Our findings add support to the existing dietary guidelines that healthy diets might also have potential benefits to maternal mental health.

Psychological Distress During Pregnancy: Cross-Sectional Prevalence and Associated Risk Factors in a South African Sample

The prevalence and risk factors associated with peripartum psychological distress-a unifying factor among common mental disorders (CMDs)-are not widely understood in underresourced settings. Cross-sectional data were collected from 664 pregnant women who reported for antenatal care at any of one of the 11 midwife and obstetrics units in Cape Town, South Africa. The prevalence of prepartum psychological distress was 38.6%. Associated factors included low socioeconomic status as measured by asset ownership (odds ratio [OR], 1.45; 95% CI, 1.24-1.68), recent physical abuse and/or rape (OR, 1.94; 95% CI, 1.57-2.40), complications during a previous birth (OR, 1.18; 95% CI, 1.01-1.38), and having given birth before (OR, 1.61; 95% CI, 1.21-2.14). The high prevalence of psychological distress is consistent with those found in other South African studies of peripartum CMDs. If effective context-specific interventions are to be appropriately designed, closer investigation of a broader symptomology associated with peripartum CMDs in these settings is warranted.

Different types of low back pain in relation to pre- and post-natal maternal depressive symptoms

Background

Low back pain (LBP) is a common musculoskeletal problem during pregnancy, with an estimated prevalence ranging from 30–78% (Mota MJ et al. J Back Musculoskelet Rehabil 28(2):351-7,2015 and Abebe E et al. J Med Sc Tech 3(3). 37-44,2014). Women reporting LBP are at increased risk of developing perinatal depression. Pregnancy-related LBP is highly heterogeneous and can be divided into lumbar pain (LP), posterior pelvic pain (PPP), and combined pain (CP). Therefore, the purpose of this study was to investigate the associations between LBP and perinatal depressive symptoms.

Methods

This was a retrospective case-control study conducted from January 2016 to April 2019. A total of 484 pregnant women were enrolled in this study: a case group of 242 pregnant women who were diagnosed with LBP and an age-matched control group of 242 pregnant women without LBP. The Edinburgh Postnatal Depression Scale (EPDS), LBP characteristics, and questionnaires about pregnancy that included demographic, parity, work, comorbidity, and previous pregnancy data were completed and compared between the case group and the control group.

Results

A total of 68 of 242 (28.1%) women experienced PPP, 142 (58.7%) had lumbar pain(LP), and 32 (13.2%) had combined pain. Furthermore, 26.5% of women with prenatal depression in the LP subgroup remained depressed 6 months postnatally, while the percentages for women in the PPP subgroup and CP subgroup were just 10.6% and 15.6%, respectively. The percentage of women who recovered anytime between delivery and six months postnatally in the PPP subgroup was significantly higher than that in the LP subgroup (31.7% vs. 14.7%, P < 0.001).

Conclusions

There is a difference in the prevalence of prenatal, postnatal, and perinatal depressive symptoms among pregnant women with different types of LBP. It is necessary to screen prenatal and postnatal depression separately and differentiate the types of LBP during pregnancy. Attention to these factors may help to outline better management strategies to improve maternal health.

Association of Parental Mental Illness With Child Injury Occurrence, Hospitalization, and Death During Early Childhood

IMPORTANCE

Injury is a leading cause of childhood morbidity and mortality worldwide. Serious mental illness (SMI) is a major contributor to the global burden of disease.

OBJECTIVE

To compare injury event rates in children from birth to 5 years of age among Taiwanese children with and without parents with SMI, including schizophrenia, bipolar disorder, and major depressive disorder.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective cohort study of an 11-year Taiwanese birth cohort used data from the Taiwan National Health Insurance Research Database (covering 99% of Taiwanese citizens), the Maternal and Child Health Database, and birth and death certificate databases. The study included 1 999 322 singletons with Taiwanese citizenship born from January 1, 2004, to December 31, 2014, and followed up from birth to their fifth birthday, December 31, 2014, or the date of death, yielding a total of 7 741 026 person-years. Data analysis was performed from April 20, 2017, to September 24, 2019.

EXPOSURES

Physician-diagnosed parental SMI defined using outpatient and inpatient records from 6 years before the child's birth to 5 years after delivery.

MAIN OUTCOME AND MEASURES

Rates of medically attended injury events, injury hospitalization, and injury death retrieved from outpatient records, inpatient records, and death certificates. Generalized estimating equation for log-linear models estimated injury incidence rate ratios (IRRs) comparing parental SMI-exposed children and unexposed children.

RESULTS

The study cohort included 1 999 322 singletons (52.1% males without parental SMI and 52.2% males with parental SMI). Incidence rates of child injury-related outcomes were higher among children exposed to parental SMI (294.8 injury events per 1000 person-years) compared with children who were unexposed (256.1 injury events per 1000 person-years). After adjustment for sociodemographic factors, children with parental SMI had higher rates of injury events (IRR, 1.14; 95% CI, 1.13-1.15), injury hospitalization (IRR, 1.49; 95% CI, 1.42-1.57), and injury death (IRR, 1.82; 95% CI, 1.38-2.39) compared with unexposed children. The results were confirmed in sensitivity analyses. Appendicitis, a negative control outcome, was not associated with parental SMI (IRR, 1.10; 95% CI, 0.94-1.28). In addition, children with and without parental SMI had similar patterns of preventive health care. The mean (SD) number of prenatal visits was 8.09 (2.50) for children with parental SMI and 8.17 (2.47) among unaffected children. The mean (SD) number of well-child visits was 5.70 (2.24) for children with parental SMI and 5.80 (2.21) among unaffected children.

CONCLUSIONS AND RELEVANCE

In this study, children with parental SMI had increased risk of injury, particularly serious injury. Excess risk may be reduced by providing effective mental health treatment, parenting support, and home safety education to parents with SMI who are raising young children.

Nutritional and immunological factors in breast milk: A role in the intergenerational transmission from maternal psychopathology to child development

Perinatal psychopathologies affect more than 25% of women during and after their gestational period. These psychiatric disorders can potentially determine important biological variations in their organisms, affecting many different physiological and metabolic pathways. Of relevance, any of these changes occurring in the mother can alter the normal composition of breast milk, particularly the concentration of nutritional and inflammatory components, which play a role in child brain functioning and development. Indeed, there is evidence showing that changes in milk composition can contribute to cognitive impairments and alterations in mental abilities in children. This review aims to shed light on the unique intergenerational role played by breast milk composition, from maternal psychopathologies to child development.

Advancing preventive interventions for pregnant women who are opioid using via the integration of addiction and mental health research

Purpose of Review

This review examines how research focused on treatment for opioid use in perinatal populations and preventive interventions for postpartum psychopathology have remained separate, despite significant overlap.

Recent Findings

Guidelines for best practice in caring for pregnant women with opioid use disorder suggest the use of medication-assisted treatment with additional comprehensive care, including behavioral and mental health interventions. However, intervention research often mutually excludes these two populations, with studies of behavioral interventions for opioid use excluding women with psychopathology and research on preventive interventions for postpartum psychopathology excluding women who are substance using.

Summary

There is a limited evidence-base to inform the selection of appropriate preventive interventions for pregnant women with opioid use disorder that can address opioid use and/or treatment adherence and concurrent mental health risks. We argue it is critical to integrate research on pregnant women who are opioid using and preventive perinatal mental health interventions to catalyze pivotal change in how we address the opioid epidemic within this growing population.

Severe Maternal Morbidity Among a Cohort of Post-9/11 Women Veterans

Background: Maternal morbidity and mortality are key indicators of women's health status and quality of care. Maternal morbidity and mortality are high and rising in the United States. There has been no evaluation of severe maternal morbidity and mortality among veteran women, although population characteristics suggest that they may be at risk. This study aimed to evaluate a surveillance methodology at the U.S. Department of Veterans Affairs (VA) and describe the characteristics of women veterans who experienced severe maternal morbidity events. Materials and Methods: The study sample derived from a national sample of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who were enrolled for care at the VA. The surveillance methodology followed a recommended process of case identification and chart review following a standardized guide. Centers for Disease Control and Prevention (CDC) International Classification of Diseases codes for maternal morbidity were applied to billing, inpatient, and outpatient data for 9,829 pregnancies among 91,061 veteran women between January 1, 2014 and December 31, 2016. Descriptive statistics is reported. Results: One hundred twenty-seven pregnancies with severe maternal morbidity events were identified, 66 of which were confirmed after chart review. The positive predictive value of CDC indicators to identify cases was 0.52. High rates of mental health problems, obesity, rurality, maternal conditions, and racial discrepancies were noted among veterans who experienced severe maternal morbidity events. Conclusions: Severe maternal morbidity affects a significant number of veteran women. Systematic reporting of pregnancy outcomes and a multidisciplinary review committee would improve surveillance and case management at the VA. The VA is uniquely positioned to develop innovative comanagement strategies, especially in the area of perinatal mental health.

Understanding the lived experiences of severe postnatal psychiatric illnesses in English speaking South Asian women, living in the UK: a qualitative study protocol

INTRODUCTION

The South Asian population is the UK's largest and fastest growing minority ethnic group. There is evidence to suggest the lay understanding of postnatal psychiatric illnesses of this group may fall outside the purview of Western biomedical perspectives. Alternative explanations include psychosocial, cultural and spiritual factors. Approaching psychiatric illnesses through a social perspective includes gaining insight to the patient's subjective experiences and understandings via qualitative inquiry. The objectives of this qualitative study are to explore South Asian women's narrative of living with a severe postnatal psychiatric illness and experiences of Perinatal Mental Health Services, care and support.

METHODS AND ANALYSIS

Data collection is ongoing and will continue until 31 December 2018. Participants will be identified and recruited from Perinatal Mental Health Services in Birmingham and London. Eligible participants will be English speaking South Asian females aged 18 years or above with the capacity to give written informed consent. Participants are clinically diagnosed with a severe postnatal psychiatric illness. This qualitative study uses individual in-depth face-to-face interviews that aim to last 1 hour. Interviews will be audio recorded with participants' permission. Interview audio recordings will be transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). The primary goal of IPA is for the researcher to closely study and interpret how individuals make sense of their life experiences in a particular context by drawing on the fundamental principles of phenomenology, hermeneutics and idiography.

ETHICS AND DISSEMINATION

The University of Birmingham, the South Birmingham Research Ethics Committee and the Health Research Authority have approved this study (approvals date: 18-12-2017 ref: 17/WM/0350). Local capability and capacity have been confirmed from Trust Research and Development departments. The researchers plan to publish the results from this study in journals and present findings at academic conferences.

Women's experiences of severe postnatal psychiatric illness: a systematic review protocol

BACKGROUND

Super diversity has become a twenty-first-century phenomena in the UK. The Five Year Forward View Plan for Mental Health commits to improving access to Perinatal Mental Health services for all new mothers. Existing research indicates various postnatal mental illness aetiologies, traditional practices and beliefs, which are important to explore during medical consultation to achieve a collaborative relationship between the patient and clinician. The study of severe postnatal psychiatric illnesses is well established in the quantitative literature; however, the subjective experiences of mothers with severe psychiatric illnesses after childbirth have been given little attention. The aim of this systematic review is to synthesise the small body of qualitative findings, which will achieve a deeper understanding of mothers' experiences and understandings. This integration of qualitative data is invaluable in facilitating culturally competent strategies in Western settings and informing future research.

METHODS/DESIGN

This protocol proposes a systematic review of qualitative literature of severe postnatal psychiatric illnesses, using a meta-ethnography approach following the PRISMA-P guidelines. A comprehensive search strategy will be developed to undertake a systematic search via online databases to identify eligible articles. Studies will be considered for eligibility if they include mothers aged 18 and over who have been diagnosed with a severe psychiatric illness during the postnatal period; present primary data on women's illness experiences; use qualitative methods. Titles and abstracts will be screened by the primary reviewer to identify potential papers. Two independent reviewers will access and read texts in full and agree on the final list of included studies. Discrepancies will be resolved via consultation with a third independent reviewer. The final list of included studies for review will be methodologically appraised by two independent reviewers using the Critical Appraisal Skills Programme. This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42018093674.

DISCUSSION

To date, no systematic review following a meta-ethnographic approach on qualitative explorations of mothers worldwide diagnosed with severe postnatal psychiatric illnesses has been conducted. An amalgamation of this information enables a deeper understanding of how severe postnatal psychiatric illnesses manifests across cultures. This information is useful when devising culturally competent care.

SYSTEMATIC REVIEW REGISTRATION

CRD42018093674.

The expectant social mind: A systematic review of face processing during pregnancy and the effect of depression and anxiety

Pregnancy carries enormous changes in the psychological and neurophysiological domains. It has been suggested that pregnant women undergo a cognitive reorganization aimed at increasing the salience of social stimuli (i.e., the tendency of social cues to capture observer's attention, so that their processing results prioritized). The goal of the present work was to systematically review the empirical evidence of a change in face processing during pregnancy. Moreover, we explored whether face processing is associated with antenatal depression and anxiety and the extent to which this is part of a potential mechanism to explain detrimental effects of maternal psychopathology on infant outcomes. We identified 19 relevant studies and discussed them based on their methodological qualities. The results of the review suggest that even though it is not possible to draw firm conclusions, pregnancy is likely to be a plasticity window for face processing at the behavioral and neural levels. Evidence confirms the detrimental effect of depression and anxiety on face processing during pregnancy. Clinical implications for parenting interventions are discussed.

Mental Health Across the Reproductive Cycle in Women Veterans

Introduction

Premenstrual, perinatal, and/or perimenopausal psychiatric problems require specific screening, assessment, and treatment strategies. The scope of these reproductive-linked psychiatric symptoms among women veterans is unknown. Due to high rates of sexual trauma among women veterans, it is also important to ascertain relationships between sexual trauma experiences and reproductive cycle mood problems. This pilot study investigates the prevalence of self-reported premenstrual, perinatal, and perimenopausal emotional problems and whether these correlate with pre-military sexual abuse, military sexual harassment, and/or military sexual assault, among veterans receiving psychiatric evaluations within a Veterans Administration Women's Health Clinic.

Materials and Methods

Participants included all women veterans (N = 186) who received psychiatric evaluations within a Veterans Administration Women's Health Clinic over a 13-mo period. Evaluations included a clinical questionnaire, a psychiatric interview, and medical record review. De-identified data were extracted from a clinical data repository for this descriptive study.

Results

High proportions of study participants reported emotional problems premenstrually (43.3%), during pregnancy (35.1%), postpartum (30.4%), or during perimenopause (31.2%). Unintended pregnancy (73.3% of pregnancies) and pregnancy loss (56.6% of women who had been pregnant) were prominent perinatal stressors. Military sexual harassment was significantly associated with emotional problems during pregnancy and postpartum.

Conclusion

These pilot data suggest the need for further study of the reproductive mental health needs of women veterans and their relationship with sexual trauma. The findings underscore the need for Veterans Administration facilities and other providers of veterans' health care to be prepared to detect, diagnose, and treat premenstrual, perinatal, and perimenopausal mental health problems.

Pharmaceutical strategies for smoking cessation during pregnancy

Introduction: Tobacco use is the most preventable cause of death worldwide, with over 7 million deaths per year. Smoking during pregnancy causes harm to the mother, fetus, and can result in problems for the infant from childhood into adulthood. Practitioners should ask all expectant mothers about tobacco use. For expectant mothers who smoke or recently quit, practitioners should advice to quit and provide psychosocial interventions. Rates of smoking during pregnancy differ between geographical locations, with estimates of 10.8% in the UK and 7.2% in the US. Practitioners should provide expectant mothers unable to quit smoking with information about the risks and benefits of pharmacotherapy and use a patient-centered approach to determine the use. Although there is no definitive evidence on birth outcomes, nicotine replacement therapy and bupropion are adequate pharmacotherapies to help those unable to quit. Areas covered: Herein, this author looks at the various pharmaceutical strategies to help patients cease smoking and provides expert perspectives on the subject. Expert opinion: Additional research on pharmacotherapy is warranted, especially with varenicline. Practitioners working with pregnant patients should be familiar with the evidence for pharmacotherapy in smoking cessation during pregnancy. This evidence can be difficult to navigate due to conflicting results and limitations with the trials.