The role of estrogen therapy in postpartum psychiatric disorders: an update

Ameliorating Effect of the Edible Mushroom Hericium erinaceus on Depressive-Like Behavior in Ovariectomized Rats

Estrogen deficiency during menopause causes a variety of neurological symptoms, including depression. The edible Lion's Mane mushroom, Hericium erinaceus (Bull.: Fr.) Pers. (HE), is a medicinal mushroom that has the potential for a neuroprotective effect and ameliorating neurological diseases, such as depression, anxiety, and neurodegenerative diseases. HE contains phytoestrogens, including daidzein and genistein. However, the ameliorating effect of HE on menopausal symptoms is not well understood. Here we investigated the impact of methanol extract of the HE fruiting body on depressive-like behavior in postmenopausal model rats. The activation of estrogen receptor alpha (ERα) causes body weight loss and uterine weight gain. Body weight gain and uterine weight loss by estrogen deficiency in ovariectomized (OVX) rats were reversed with 17β-estradiol (E₂) but not with HE. Thus, the phytoestrogens in HE may hardly activate ERα. Estrogen receptor beta (ERβ) is expressed in the brain, and activation of ERβ ameliorates menopausal depressive symptoms. Notably, depressive-like behavior in OVX rats evaluated in forced swim test was reduced by administration of not only E₂ but also HE for 92 d. Long-term activation of ERα increases the risk of breast and uterine cancers. HE, therefore, may be effective in treating menopausal depression without the risk of carcinogenesis caused by ERα activation.

THE NEUROENDOCRINOLOGICAL ASPECTS OF PREGNANCY AND POSTPARTUM DEPRESSION

Introduction

Ties between the endocrine system and mental health are undeniably a consistent point of interest in modern day medicine. Furthermore, mental disturbances due to hormonal changes following childbirth have been mentioned in medical literature since Hippocrates. Considering the dramatic endocrine, paracrine and autocrine changes that occur during gestation, labour and postnatal phase, hormonal theories are not to be ignored in the treatment of postpartum disorders.

Results

Reproductive hormones are known to modulate behavioural, emotional and cognitive response, therefore rapid changes in estradiol and progesterone plasma concentrations during pregnancy and labour create a vulnerable terrain leading towards postpartum disorders. New research shows that women suffering from postpartum disorders have abnormal neural responses, suggesting a neuroendocrine explanation for postpartum syndromes.

Conclusion

To facilitate further research in this area, we present new information on several hormonal interactions and the psychiatric response involved in pregnancy and labour, offering an interdisciplinary outlook on pregnancy and postpartum disorders. There is enough evidence to suggest that estradiol, progesterone, oxytocin, cortisol and thyroid hormones are some of many hormones involved in postpartum syndromes and tackling their perinatal imbalance with pharmacological substituents or antagonists could be useful as an adjuvant form of treatment in future patients.

SULFATION PATHWAYS: The steroid sulfate axis and its relationship to maternal behaviour and mental health

Steroid hormones can exist in functionally dissociable sulfated and non-sulfated (free) forms and can exert profound effects on numerous aspects of mammalian physiology; the ratio of free-to-sulfated steroids is governed by the antagonistic actions of steroid sulfatase (STS) and sulfotransferase (SULT) enzymes. Here, I examine evidence from human and animal model studies, which suggests that STS and its major substrate (dehydroepiandrosterone sulfate, DHEAS) and product (DHEA) can influence brain function, behaviour and mental health, before summarising how the activity of this axis varies throughout mammalian pregnancy and the postpartum period. I then consider how the steroid sulfate axis might impact upon normal maternal behaviour and how its dysfunction might contribute towards risk of postpartum psychiatric illness. Understanding the biological substrates underlying normal and abnormal maternal behaviour will be important for maximising the wellbeing of new mothers and their offspring.

Mothers with acute and chronic postpartum psychoses and impact on the mother-infant interaction

BACKGROUND

Maternal postpartum psychoses pose a serious risk to the mother-infant interaction. It is unclear how different subtypes of postpartum psychosis, including acute and chronic, might differentially affect the mother-infant interaction.

METHOD

A systematic search of electronic journal databases was performed.

RESULTS

This systematic review yielded 17 studies with adequate overall study quality. They focused on child custody and involvement of social services as indirect indicators of the mother-infant interaction, observed mother-infant interactions as direct indicators, or potential transitional mechanisms, including memory processing, mind-mindedness, and affect recognition, that may partially explain the effects of psychotic disorders. An acute onset of psychosis during the postpartum period (de novo or relapse) was typically related to better mother-infant interactions. Mothers with schizophrenia have the highest risk of child displacement, and interventions by social services were more likely. However, mothers with postpartum schizophrenia did not exhibit more harm to the child or self-harm than mothers with postpartum depression. Heterogeneity of methodology, case definitions, and assessments characterized the studies; hence, they were not pooled.

CONCLUSIONS

In addition to evaluating social risk factors in patients with acute onset and chronic psychoses during the postpartum period, negative preconceptions about motherhood and schizophrenia have to be carefully examined. Clinical research on postpartum psychoses should consider the onset criteria, prevalence of self-harm or harm to the child, significance of specific (e.g., religious) delusions and expressed hostility toward the child. More studies on the impact of first-onset (de novo) postpartum psychoses on the mother-infant interaction are needed.

Improvement of neurological disorders in postmenopausal model rats by administration of royal jelly

OBJECTIVE

Royal jelly (RJ) from honeybees (Apis mellifera) has estrogenic activity. Estrogen deficiency after menopause leads to a high risk of memory impairment and depression as well as metabolic syndrome and osteoporosis. We here investigated the effect of RJ on memory impairment and depression-like behaviors in ovariectomized (OVX) rats.

METHODS

OVX rats were administered with RJ for 82 days. Hippocampus-dependent spatial memory and depression-like behaviors were assessed by the Morris water maze test and the forced swimming test, respectively. The weights of body, brain and uterus and the contents of protein and myelin galactolipids including galactosylceramide and sulfatide were measured.

RESULTS

Memory impairment and depression-like behaviors in OVX rats were recovered to the levels of sham-operated rats by RJ administration. Increased body weight and decreased uterine weight in OVX rats were recovered to the levels of sham-operated rats by 17β-estradiol (E2) administration but not by RJ administration. In contrast, brain weight was slightly increased by RJ administration but not by E2 administration. The contents of protein and myelin galactolipids were higher in the brains of RJ-administered OVX rats than in the brains of E2-administered OVX rats.

CONCLUSION

The results suggest that RJ has a beneficial effect on neurological symptoms of a menopausal disorder.

Using animal models to study post-partum psychiatric disorders

The post-partum period represents a time during which all maternal organisms undergo substantial plasticity in a wide variety of systems in order to ensure the well-being of the offspring. Although this time is generally associated with increased calmness and decreased stress responses, for a substantial subset of mothers, this period represents a time of particular risk for the onset of psychiatric disorders. Thus, post-partum anxiety, depression and, to a lesser extent, psychosis may develop, and not only affect the well-being of the mother but also place at risk the long-term health of the infant. Although the risk factors for these disorders, as well as normal peripartum-associated adaptations, are well known, the underlying aetiology of post-partum psychiatric disorders remains poorly understood. However, there have been a number of attempts to model these disorders in basic research, which aim to reveal their underlying mechanisms. In the following review, we first discuss known peripartum adaptations and then describe post-partum mood and anxiety disorders, including their risk factors, prevalence and symptoms. Thereafter, we discuss the animal models that have been designed in order to study them and what they have revealed about their aetiology to date. Overall, these studies show that it is feasible to study such complex disorders in animal models, but that more needs to be done in order to increase our knowledge of these severe and debilitating mood and anxiety disorders.

Prevention and treatment of postnatal depression

Postnatal depression is a common condition that may have a significant negative impact on both infant and mother, often remaining undiagnosed and untreated. Development of effective means of detection, prevention and treatment of postnatal depression is a major health challenge. The objective of this article is to critically review pharmacological, psychological and psychosocial approaches of prevention and treatment for postnatal depression. There is little evidence of short-term success for preventive interventions and some evidence of short-term success for treatment interventions. No preventive or therapeutic studies, however, have provided evidence for long-term success. There is a need for future research into the prevention and treatment of postnatal depression including the assessment of long-term effects on the child's development as well as feasibility in relation to cost-effectiveness.

Risk factors for postpartum depression among abused and nonabused women

OBJECTIVE

The objective of the study was to compare risk factors for postpartum depression among women exposed vs not exposed to intimate partner violence and to assess the timing of abuse in relation to postpartum depression.

STUDY DESIGN

This was a retrospective cohort study utilizing data from the Canadian Maternity Experiences Survey, a telephone survey at 5-10 months postpartum. Survey questions were adapted from the Canadian Violence Against Women Survey and the Edinburgh Post-Natal Depression Scale.

RESULTS

Among abused women, younger (15-19 years), and older (35 years old and older), age was associated with postpartum depression, adjusted odds ratio (aOR, 2.29; 95% confidence interval [CI], 1.17-4.51) and (aOR, 2.33; 95% CI, 1.02-5.34) as was unemployment (aOR, 1.41; 95% CI, 1.06-1.84), foreign birth (aOR, 2.04; 95% CI, 1.35-3.09], and low income (aOR, 1.68; 95% CI, 1.25-2.25) among nonabused women. Postpartum depression was significantly associated with abuse occurring only prior to pregnancy (aOR, 3.28; 95% CI, 1.86-5.81), starting postpartum (aOR, 4.76; 95% CI, 1.41-16.02), and resuming postpartum (aOR, 3.81; 95% CI, 1.22-11.88).

CONCLUSION

Among pregnant women, subgroups defined by abuse exposure differ in their risk profile for postpartum depression.

Estrogens and memory in physiological and neuropathological conditions

Ovarian hormones can influence brain regions crucial to higher cognitive functions, such as learning and memory, acting at structural, cellular and functional levels, and modulating neurotransmitter systems. Among the main effects of estrogens, the protective role that they may play against the deterioration of cognitive functions occurring with normal aging is of essential importance. In fact, during the last century, there has been a 30 years increase in female life expectancy, from 50 to 83 years; however, the mean age of spontaneous menopause remains stable, 50-51 years, with variability related to race and ethnicity. Therefore, women are now spending a greater fraction of their lives in a hypoestrogenic state. Although many cognitive functions seem to be unaffected by normal aging, age-related impairments are particularly evident in tasks involving working memory (WM), whose deficits are a recognized feature of Alzheimer's disease (AD). Many studies conducted over the past two decades showed that the female gonadal hormone estradiol can influence performance of learning and memory tasks, both in animal and humans. There is a great deal of evidence, mostly from animal models, that estrogens can facilitate or enhance performance on WM tasks; therefore, it is very important to clarify their role on this type of memory. To this aim, in this review we briefly describe the most relevant neurobiological bases of estrogens, that can explain their effects on cognitive functioning, and then we summarize the results of works conducted in our laboratory, both on animals and humans, utilizing the menstrual/estrous cycle as a useful noninvasive model. Finally, we review the possible role of estrogens in neuropathological conditions, such as AD and schizophrenia.

On categorizing gestational, birth, and neonatal complications following late pregnancy exposure to antidepressants: the prenatal antidepressant exposure syndrome

INTRODUCTION

Late in utero exposure to antidepressants has been suspected of adversely impacting pregnancy outcome and compromising neonatal adaptation. Hence, the necessity exists to analyze published information on antidepressant use during late pregnancy to individuate potential recurrent patterns of iatrogenic complications.

METHODS

Computerized searches on MEDLINE, PsycINFO, ENBASE, and Cochrane Library through February 10, 2010 were performed for selecting literature information and investigating the safety of antidepressants when used during late pregnancy.

RESULTS

Antidepressant treatment during late pregnancy may increase the rates of poor pregnancy outcome and neonatal withdrawal/toxic reactions.

CONCLUSIONS

Because both gestational complications and neonatal adverse events acknowledge the same etiology, the author suggests including such iatrogenic events under the definition of prenatal antidepressant exposure syndrome, in order to increase clinicians' awareness about the spectrum of risks which may concern the mother-infant pair when antidepressant treatment is deemed indispensable during late pregnancy.

Anhedonia in postpartum rats

Postpartum depression (PPD) is a debilitating illness, yet little is known about its causes. The purpose of this study was to examine a major symptom of depression during the postpartum period, anhedonia, by comparing sucrose preference in female rats that had undergone actual pregnancy or hormone-simulated pregnancy (HSP) to their respective controls. Whereas HSP rats showed significantly less preference than vehicle control rats for 1% sucrose solution during the first three weeks of the "postpartum" period, previously pregnant females showed only slightly depressed sucrose preference for the first 1-2 days postpartum, compared to non-pregnant controls. Habituation to 1% sucrose during the pregnancy period, which increased preference upon later testing in previously pregnant rats tested on postpartum day 2, did not significantly increase preference in HSP rats, suggesting that depressed preference in the latter group was not due to neophobia. Pre-treatment with desipramine did not prevent suppressed sucrose preference in HSP rats, and preference was even further suppressed following chronic sertraline treatment. These results suggest that estradiol withdrawal following HSP may cause anhedonia during the early "postpartum" period. In contrast, females that have undergone actual pregnancy are less likely to show this effect, suggesting that postpartum hormonal changes other than the dramatic decline in estradiol may buffer its negative mood effects.

An endocrine perspective on the role of steroid hormones in the antidepressant treatment efficacy of transcranial magnetic stimulation

Evidence from recent meta-analyses indicates that transcranial magnetic stimulation (TMS) is moderately effective in the treatment of major depressive disorder (MDD). Individual differences in the susceptibility to TMS are suggested to underlie a significant portion of the variability in antidepressant efficacy observed in TMS trials. Interestingly, recent findings suggest a moderating role for steroid hormones in the antidepressant efficacy of TMS in women. Steroid hormones are known to have strong activational and organizational influences on the brain and may upregulate the efficacy of TMS by way of modulating cortical excitability in a sex-dependent manner. Here we propose that the measurement and manipulation of steroid hormones could be crucial steps in the development of successful individually based TMS protocols for the treatment of MDD.

Differentiation and clinical implications of postpartum depression and postpartum psychosis

Postpartum depression and postpartum psychosis are serious mood disorders encountered by nurses working in a variety of settings. Postpartum depression refers to a nonpsychotic depressive episode, while postpartum psychosis refers to a manic or affective psychotic episode linked temporally with childbirth. The nursing profession plays a crucial role in the early identification and treatment of these postpartum mood disorders. This article explains the classification, clinical presentation, epidemiology, management, and long-term outcomes of postpartum depression and postpartum psychosis.

Lifetime physical and sexual abuse and the risk for depression symptoms in the first 8 months after birth

Despite the growing body of evidence on the significance of postpartum depression, little research has explored the contribution of lifetime or current abuse to postpartum depression. One hundred-thirty-nine women were assessed during their third trimester of pregnancy and followed for 2, 4, 6, and 8 months postpartum for abuse status and depression symptoms. Predictors of postpartum depression were also assessed. Few women reported current abuse experiences, although 37% reported having lifetime physical or sexual abuse or both. Women with a lifetime history of abuse were 3.6-8.4 times more likely to experience postpartum depression than their nonabused peers at each measurement time. This effect steadily increases during the first 6 months after birth and decreases at the 8th month. These findings extend recent reports of the chronicity of abuse and have implications for care providers. The standard of care for abuse assessments may need to be expanded to include consideration of lifetime physical and sexual abuse experiences of pregnant and postpartum women.

Postpartum Depression: An Update

Postpartum depression occurs in at least one in seven new mothers, usually within the first 6 months after delivery. By the time of onset of postpartum depression, the mother has usually long since been discharged from the maternity hospital. Early identification and treatment of these mothers reduces both maternal and infant suffering. Careful risk–benefit decision-making regarding various treatment options in the postpartum should be discussed with the mother. Risks of untreated depression include poor bonding with the infant, lack of self care, infant neglect and infanticide.

Working memory for emotional facial expressions: role of the estrogen in young women

Physiological hormonal fluctuations during the menstrual cycle, postpartum, and menopause have been implicated in the modulation of mood, cognition, and affective disorders. Taking into account that women's performance in memory tasks can also fluctuate with circulating hormones levels across the menstrual cycle, the cognitive performance in a working memory task for emotional facial expressions, using the six basic emotions as stimuli in the delayed matching-to-sample, was evaluated in young women in different phases of the menstrual cycle. Our findings suggest that high levels of estradiol in the follicular phase could have a negative effect on delayed matching-to-sample working memory task, using stimuli with emotional valence. Moreover, in the follicular phase, compared to the menstrual phase, the percent of errors was significantly higher for the emotional facial expressions of sadness and disgust. The evaluation of the response times (time employed to answer) for each facial expression with emotional valence showed a significant difference between follicular and luteal in reference to the emotional facial expression of sadness. Our results show that high levels of estradiol in the follicular phase could impair the performance of working memory. However, this effect is specific to selective facial expressions suggesting that, across the phases of the menstrual cycle, in which conception risk is high, women could give less importance to the recognition of the emotional facial expressions of sadness and disgust. This study is in agreement with research conducted on non-human primates, showing that fluctuations of ovarian hormones across the menstrual cycle influence a variety of social and cognitive behaviors. Moreover, our data could also represent a useful tool for investigating emotional disturbances linked to menstrual cycle phases and menopause in women.

The effects of estradiol on central serotonergic systems and its relationship to mood in women

Lifetime prevalence rates of depression are higher in women than men. Because this gender disparity appears after the onset of puberty and declines after menopause, gonadal hormones may play a role in women's increased vulnerability to dysphoric states. Estrogens have powerful effects beyond their role in reproduction. Fluctuations in estrogen occur naturally throughout the reproductive years and can be associated with disruptions in mood. Treatment for depression with exogenous estrogen has produced equivocal results. To shed light on the complex interactions among estrogens, serotonin, and mood, we briefly examine (a) central serotonin systems and their relationship to mood and mood disorders, (b) nonreproductive effects of estrogens on those systems, (c) potential points of intersection between serotonin systems and estrogens, and (d) research into the use of exogenous estrogen in depression in women. In conclusion, we reiterate the call for carefully controlled research into the etiology and treatment of depression in women.

Serotonin reuptake inhibitor-induced perinatal complications

There are a growing number of concerns about the utilization of serotonin reuptake inhibitors (SRIs) in late pregnancy and the onset of perinatal complications. This review aimed to analyze and summarize the studies evaluating the risk of perinatal complications (such as low birth weight, preterm delivery, withdrawal or toxic phenomena, and other detrimental events/poor neonatal outcomes) related to maternal SRI use in late pregnancy. A computerized search of MEDLINE (1966-January 2007) and PsycINFO (1974-January 2007) databases was performed. Articles describing perinatal complications after late in utero exposure to SRIs were selected and also reviewed for additional references. Fifty studies met the inclusion criteria. Exposure to SRIs late in pregnancy is clearly associated with an increased risk of infants developing a constellation of symptoms, including CNS and respiratory effects, often requiring close infant observation and supportive or specific treatment in intensive care units. Such symptoms are not always due to toxic or withdrawal reactions. Indeed, some evidence suggests that SRIs may interfere with the physiology of the respiratory system and parasympathetic activity in neonates. Of the most methodologically relevant studies reviewed, 50% have been published in the last 3 years. Hence, it is possible that further concerning data will become available in the future. For these reasons, the opportunity of tapering and discontinuing SRIs in late pregnancy should be taken into consideration, although to date the evidence to support such a clinical decision is preliminary.