Cognitive processing of infant stimuli in pregnant women with and without affective disorders and the association to postpartum depression

Prenatal affective cognitive training to reduce the risk of postpartum depression (PACT): study protocol for a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) affects 30-50% of women with a history of previous depression or bipolar disorder and 8% of women with no history of depression. Negative cognitive biases in the perception of infant cues and difficulties with emotion regulation are replicated risk factors. Current interventions focus on detecting and treating rather than preventing PPD. The aim of this randomized controlled intervention trial is therefore to investigate the potential prophylactic effects of prenatal affective cognitive training for pregnant women at heightened risk of PPD.

METHODS

The study will enrol a total of 292 pregnant women: 146 at high risk and 146 at low risk of PPD. Participants undergo comprehensive assessments of affective cognitive processing, clinical depressive symptoms, and complete questionnaires at baseline. Based on the responses, pregnant women will be categorized as either at high or low risk of PPD. High-risk participants will be randomized to either prenatal affective cognitive training (PACT) or care as usual (CAU) immediately after the baseline testing. The PACT intervention is based on emerging evidence for efficacy of affective cognitive training approaches in depression, including cognitive bias modification, attention bias modification, mindfulness-inspired emotion regulation exercises, and working memory training. Participants randomised to PACT will complete five individual computerised and virtual reality-based training sessions over 5 weeks. The primary outcome is the difference between intervention arms in the incidence of PPD, assessed with an interview 6 months after birth. We will also assess the severity of depressive symptoms, rated weekly online during the first 6 weeks postpartum.

DISCUSSION

The results will have implications for future early prophylactic interventions for pregnant women at heightened risk of PPD. If the PACT intervention reduces the incidence of PPD, it can become a feasible, non-invasive prophylactic strategy during pregnancy, with positive mental health implications for these women and their children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06046456 registered 21-09-2023, updated 08-07-2024.

Affective cognition in response to infant stimuli in pregnant compared with non-pregnant women

Physiological, neurocognitive, and psychological changes facilitates adaptation to motherhood. This cross-sectional study aimed to examine differences between pregnant and non-pregnant women in affective cognitive and psychophysiological responses to infant stimuli. We hypothesized that pregnant women would display (I) reduced negative emotional reactivity and perception of distressed infant stimuli, (II) increased attention toward infants compared to adults, and (III) greater psychophysiological response to infant distress. The sample comprised 22 pregnant women (22-38 weeks gestation) and 18 non-pregnant nulliparous women. Four computerized tasks were administered to measure affective cognitive processing of infant stimuli, while recording facial expressions, electrodermal activity, and eye gazes. Results indicated that pregnant women exhibited fewer negative facial expressions, reported less frustration when exposed to distressed infant cries, and showed greater attention to emotional infant faces compared to non-pregnant women, but the differences did not remain statistically significant after correction for multiple comparisons. No differences were observed in psychophysiological responses. The findings indicate a possible pregnancy-mediated effect regarding the cognitive processing of infant stimuli, potentially as preparation for motherhood. Future research with larger samples and longitudinal design is needed to understand the predictors, timing, and plasticity of cognitive changes during pregnancy.

Differences in facial emotion recognition between bipolar disorder and other clinical populations: A systematic review and meta-analysis

Facial emotion (or expression) recognition (FER) is a domain of affective cognition impaired across various psychiatric conditions, including bipolar disorder (BD). We conducted a systematic review and meta-analysis searching for eligible articles published from inception to April 26, 2023, in PubMed/MEDLINE, Scopus, EMBASE, and PsycINFO to examine whether and to what extent FER would differ between people with BD and those with other mental disorders. Thirty-three studies comparing 1506 BD patients with 1973 clinical controls were included in the present systematic review, and twenty-six of them were analyzed in random-effects meta-analyses exploring the discrepancies in discriminating or identifying emotional stimuli at a general and specific level. Individuals with BD were more accurate in identifying each type of emotion during a FER task compared to individuals diagnosed with schizophrenia (SCZ) (SMD = 0.27; p-value = 0.006), with specific differences in the perception of anger (SMD = 0.46; p-value = 1.19e-06), fear (SMD = 0.38; p-value = 8.2e-04), and sadness (SMD = 0.33; p-value = 0.026). In contrast, BD patients were less accurate than individuals with major depressive disorder (MDD) in identifying each type of emotion (SMD = -0.24; p-value = 0.014), but these differences were more specific for sad emotional stimuli (SMD = -0.31; p-value = 0.009). No significant differences were observed when BD was compared with children and adolescents diagnosed with attention-deficit/hyperactivity disorder. FER emerges as a potential integrative instrument for guiding diagnosis by enabling discrimination between BD and SCZ or MDD. Enhancing the standardization of adopted tasks could further enhance the accuracy of this tool, leveraging FER potential as a therapeutic target.

Prediction of postpartum depression with an online neurocognitive risk screening tool for pregnant women

Postpartum depression (PPD) is a severe mental illness affecting 10-15% of mothers. Emerging evidence indicates that negative neurocognitive bias in response to infant distress during pregnancy marks an increased risk of PPD. This proof-of-concept study aimed to investigate the association between negatively biased neurocognitive processing of infant distress during pregnancy and subsequent PPD and to explore the feasibility of an online risk screening tool. In the second or third trimester of pregnancy, 87 participants underwent two online tests of reactivity to and evaluation of infant distress and completed questionnaires regarding psychosocial risk factors. After birth, participants rated their depressive symptoms online and underwent a diagnostic telephone interview concerning PPD. Irrespective of depressive symptoms during pregnancy, negative reactivity to and evaluation of infant distress predicted PPD (reactivity: Exp(B)=1.33, p = 0.04) and depressive symptoms after birth (reactivity: B = 0.04, p = 0.048; evaluation: B = 0.10, p = 0.04). The negative reactivity toward infant distress showed high sensitivity and moderate specificity (89% and 77%, respectively), while the evaluation of infant distressed cries showed lower sensitivity and specificity (67% and 66%, respectively). The relatively small sample size prevented the inclusion of additional risk variables in the regression models. The replication of an association between negative neurocognitive bias during pregnancy with PPD risk is noteworthy and has clinical implications in terms of early prevention. However, the low response rate indicates that this tool is not feasible in its current form. Future larger-scale studies are needed to further investigate candidate risk factors in a brief online screening tool.

Relationship between Antenatal Mental Health and Facial Emotion Recognition Bias for Children’s Faces among Pregnant Women

The importance of identification of facial emotion recognition (FER) bias for a child’s face has been reinforced from the perspective of risk screening for future peripartum mental health problems. We attempted to clarify the relationship of FER bias for children’s faces with antenatal depression and bonding failure among pregnant women, taking into consideration their broad social cognitive abilities and experience in child raising. This study had a cross-sectional design, and participants were women in their second trimester of pregnancy. Seventy-two participants were assessed by the Edinburgh Postnatal Depression Scale (EPDS), the Mother-to-Infant Bonding Questionnaire (MIBQ), and a series of social cognitive tests. FER bias for a child’s face was assessed by Baby Cue Cards (BCC), and a larger number of disengagement responses suggest greater sensitivity to a child’s disengagement facial expressions. In a regression analysis conducted using EPDS as the dependent variable, a larger number of disengagement responses to the BCC (β = 0.365, p = 0.001) and the primipara status (β = −0.263, p = 0.016) were found to significantly contribute to antenatal depressive symptoms. Also, more disengagement responses to the BCC also significantly contributed to bonding failure as measured by the MIBQ (β = 0.234, p = 0.048). Maternal sensitivity to the child’s disengagement cues was associated with antenatal depressive symptoms and bonding failure more than the other social cognitive variables. The effects of FER bias on postpartum mental health and abusive behavior needs to be clarified by further longitudinal studies.

Short-term oestrogen as a strategy to prevent postpartum depression in high-risk women: protocol for the double-blind, randomised, placebo-controlled MAMA clinical trial

INTRODUCTION

Postpartum depression affects 10%-15% of women and has a recurrence rate of 40% in subsequent pregnancies. Women who develop postpartum depression are suspected to be more sensitive to the rapid and large fluctuations in sex steroid hormones, particularly estradiol, during pregnancy and postpartum. This trial aims to evaluate the preventive effect of 3 weeks transdermal estradiol treatment immediately postpartum on depressive episodes in women at high risk for developing postpartum depression.

METHODS AND ANALYSIS

The Maternal Mental Health Trial is a double-blind, randomised and placebo-controlled clinical trial. The trial involves three departments of obstetrics organised under Copenhagen University Hospital in Denmark. Women who are singleton pregnant with a history of perinatal depression are eligible to participate. Participants will be randomised to receive either transdermal estradiol patches (200 µg/day) or placebo patches for 3 weeks immediately postpartum. The primary outcome is clinical depression, according to the Diagnostic and Statistical Manual of Mental Disorders-V criteria of Major Depressive Disorder with onset at any time between 0 and 6 months postpartum. Secondary outcomes include, but are not limited to, symptoms of depression postpartum, exclusive breastfeeding, cortisol dynamics, maternal distress sensitivity and cognitive function. The primary statistical analysis will be performed based on the intention-to-treat principle. With the inclusion of 220 participants and a 20% expected dropout rate, we anticipate 80% power to detect a 50% reduction in postpartum depressive episodes while controlling the type 1 error at 5%.

ETHICS AND DISSEMINATION

The study protocol is approved by the Regional Committees on Health Research Ethics in the Capital Region of Denmark, the Danish Medicines Agency and the Centre for Data Protection Compliance in the Capital Region of Denmark. We will present results at scientific meetings and in peer-reviewed journals and in other formats to engage policymakers and the public.

TRIAL REGISTRATION NUMBER

NCT04685148.