Postpartum depression: a developed and validated model predicting individual risk in new mothers

Time trends in incidence of postpartum depression and depression in women of reproductive age

BACKGROUND

Little is known about the time trends of postpartum depression (PPD) and whether they differ from time trends of depression among women in general.

METHODS

Using Danish health registers, we identified a postpartum population from all women who had a liveborn child from 2000-2022. We sampled a background population by matching five women for each delivery on age and date of childbirth. Depression and PPD were measured as incident depression diagnosis or redeemed antidepressant prescription within 180 days from childbirth/matching. We described incidence rates from 2000-2022 using Poisson regression with a restricted cubic spline.

RESULTS

The study population included 1,133,947 postpartum women (669,101 unique), matched to 5,669,735 women (1,165,505 unique). Overall IR per 10,000 person-years of diagnoses was 34.3 (95% CI: 32.8-35.9) for PPD and 18.9 (95% CI: 18.3-19.4) for depression. Both IRs increased similarly over time in the main analyses, but more pronounced for PPD in primiparous and older mothers. Correspondingly, IR for prescriptions was 135.7 (95% CI: 132.7-138.8) for PPD and 209.8 (95% CI: 208.1-211.5) for depression, and both groups had fluctuating time trends.

LIMITATIONS

Depression measures were based on women who actively sought and received treatment, expectedly underestimating true disease incidence.

CONCLUSIONS

Incidence rates of PPD and depression diagnoses increased over time, especially for PPD among primiparous and older mothers. These findings could suggest either increased vulnerability or increased awareness and detection over time in these groups. Fluctuating trends overserved from prescriptions could likely be driven by external factors and not a reflection of disease trends.

Hyperemesis gravidarum theories dispelled by recent research: a paradigm change for better care and outcomes

Nausea and vomiting (NVP) affect most pregnant women. At the severe end of the clinical spectrum, hyperemesis gravidarum (HG) can be life-threatening. The condition is fraught with misconceptions that have slowed progress and left women undertreated. Herein, recent scientific advances are presented that dispel common myths associated with HG related to maternal/offspring outcomes, etiology, and evolution. There is now strong evidence that (i) HG is associated with poor outcomes, (ii) a common cause of NVP and HG has been identified, and (iii) NVP is likely a protective evolutionary mechanism that occurs throughout the animal kingdom but is no longer necessary for human survival. Therefore, it is encouraging that we are finally on the cusp of testing treatments that may put an end to unnecessary suffering.

Stratifying Risk for Postpartum Depression at Time of Hospital Discharge

Objective

Postpartum depression (PPD) represents a major contributor to postpartum morbidity and mortality. Beyond efforts at routine screening, risk stratification models could enable more targeted interventions in settings with limited resources. Thus, we aimed to develop and estimate the performance of a generalizable risk stratification model for PPD in patients without a history of depression using information collected as part of routine clinical care.

Methods

We performed a retrospective cohort study of all individuals who delivered between 2017 and 2022 in one of two large academic medical centers and six community hospitals. An elastic net model was constructed and externally validated to predict PPD using sociodemographic factors, medical history, and prenatal depression screening information, all of which was known before discharge from the delivery hospitalization.

Results

The cohort included 29,168 individuals; 2,703 (9.3%) met at least one criterion for postpartum depression in the 6 months following delivery. In the external validation data, the model had good discrimination and remained well-calibrated: area under the receiver operating characteristic curve 0.721 (95% CI: 0.707-0.734), Brier calibration score 0.088 (95% CI: 0.084 - 0.092). At a specificity of 90%, the positive predictive value was 28.0% (95% CI: 26.0-30.1%), and the negative predictive value was 92.2% (95% CI: 91.8-92.7%).

Conclusions

These findings demonstrate that a simple machine-learning model can be used to stratify the risk for PPD before delivery hospitalization discharge. This tool could help identify patients within a practice at the highest risk and facilitate individualized postpartum care planning regarding the prevention of, screening for, and management of PPD at the start of the postpartum period and potentially the onset of symptoms.

Survivors' Experiences of Hyperemesis Gravidarum

Hyperemesis gravidarum can result in life-threatening physical and psychological maternal morbidity, including severe dehydration, weight loss, electrolyte imbalance, depression, and suicidal ideation. The reported prevalence of hyperemesis gravidarum ranges from 0.3% to 3.6%. The purpose of this qualitative study was to investigate what blogs can tell us about women's experiences of hyperemesis gravidarum. Thirty-three blogs written by hyperemesis gravidarum survivors posted on Hyperemesis Australia's website were analyzed using Krippendorff's qualitative content analysis method. Clustering was used and yielded 6 themes: (1) debilitating physical and mental health problems: digging deep to persevere, (2) heartbreaking choices, (3) lack of understanding and dismissed, (4) so much guilt surrounding their unborn infant, (5) it takes a village to support women with hyperemesis gravidarum, and (6) warriors and survivors: giving back. Infusion nurses are in a perfect position to provide support and compassionate care for women who are repeatedly coming to the hospital for rehydration treatment. Infusion nurses can validate women's physical and emotional struggles with hyperemesis gravidarum and help to no longer make women feel stigmatized.

Identification of women at high risk of postpartum psychiatric episodes: A population-based study quantifying relative and absolute risks following exposure to selected risk factors and genetic liability

BACKGROUND

We quantified relative and absolute risks of postpartum psychiatric episodes (PPE) following risk factors: Young age, past personal or family history of psychiatric disorders, and genetic liability.

METHODS

We conducted a register-based study using the iPSYCH2012 case-cohort sample. Exposures were personal history of psychiatric episodes prior to childbirth, being a young mother (giving birth before the age of 21.5 years), having a family history of psychiatric disorders, and a high (highest quartile) polygenic score (PGS) for major depression. PPE was defined within 12 months postpartum by prescription of psychotropic medication or in- and outpatient contact to a psychiatric facility. We included primiparous women born 1981-1999, giving birth before January 1st, 2016. We conducted Cox regression to calculate hazard ratios (HRs) of PPE, absolute risks were calculated using cumulative incidence functions.

RESULTS

We included 8174 primiparous women, and the estimated baseline PPE risk was 6.9% (95% CI 6.0%-7.8%, number of PPE cases: 2169). For young mothers with a personal and family history of psychiatric disorders, the absolute risk of PPE was 21.6% (95% CI 15.9%-27.8%). Adding information on high genetic liability to depression, the risk increased to 29.2% (95% CI 21.3%-38.4%) for PPE.

CONCLUSIONS

Information on prior personal and family psychiatric episodes as well as age may assist in estimating a personalized risk of PPE. Furthermore, additional information on genetic liability could add even further to this risk assessment.

Predicting Patients Requiring Treatment for Depression in the Postpartum Period Using Common Electronic Medical Record Data Available Antepartum

Introduction

Depression requiring treatment in the postpartum period significantly impacts maternal and neonatal health. Although preventive management of depression in pregnancy has been shown to decrease the negative impacts, current methods for identifying at-risk patients are insufficient. Given the complexity of the diagnosis and interplay of clinical/demographic factors, we tested whether machine learning techniques can accurately identify at-risk patients in the postpartum period.

Methods

This is a retrospective cohort study of the NIH Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, which enrolled 10,038 nulliparous people. The primary outcome was depression in the postpartum period. We constructed and optimized 4 machine learning models using distributed random forest modeling and 1 logistic regression model on the basis of the NIH Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be dataset. Model 1 utilized only readily obtainable sociodemographic data. Model 2 added maternal prepregnancy mental health data. Model 3 utilized recursive feature elimination to construct a parsimonious model. Model 4 further titrated the input data to simplify prepregnancy mental health variables. The logistic regression model used the same input data as Model 3 as a proof of concept.

Results

Of 8,454 births, 338 (4%) were complicated by depression in the postpartum period. Model 3 was the highest performing, showing the area under the receiver operating characteristics curve of 0.91 (±0.02). Models 1-3 identified the 9 variables most predictive of depression hierarchically, ranging from depression history (highest), history of mental health condition, recent psychiatric medication use, BMI, income, age, anxiety history, education, and preparedness for pregnancy (lowest). In Model 4, the area under the receiver operating characteristics curve remained at 0.79 (±0.05).

Conclusions

Postpartum depression can be predicted with high accuracy for individual patients using antepartum information commonly found in electronic medical records. In addition, baseline mental health status and sociodemographic factors have a larger role in the postpartum period than previously understood.

Postpartum Depression: Screening and Collaborative Management

Perinatal mood disorders are a leading cause of disability worldwide and suicide is a leading cause of maternal death in the first year after giving birth. The three categories of perinatal mood disorders are postpartum blues, postpartum depression, and postpartum psychosis. Identifying risk factors may allow clinicians to provide patients with interventions to potentially prevent development of these disorders. Universal screening for perinatal mood disorders can lead to earlier identification and treatment. Collaborative care methods, incorporating the entire family into treatment, therapy service, and providing support services are recommended as first-line intervention strategies before moving on to pharmacologic management.

Interventions to treat and prevent postpartum depression: a protocol for systematic review of the literature and parallel network meta-analyses

INTRODUCTION

Postpartum depression has costly consequences for the mother, baby, and society. Numerous pharmacological and non-pharmacological interventions are available for the prevention and treatment of postpartum depression. To date, no attempt has been made to synthesize the evidence from comparisons of interventions both within and across these categories.

METHODS

We will perform a systematic review of the literature and perform network meta-analysis of interventions to (a) prevent and (b) treat postpartum depression. This review will include studies of primiparous or multiparous women during pregnancy or within 12 months of delivery of their baby that assess either interventions initiated during pregnancy or within 1 year of childbirth. Comparators will be other eligible interventions or control conditions. The outcome of interests will be related to the antidepressant efficacy of the interventions as well as their acceptability. The published literature will be searched in Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. The search will use a combination of standardized terms and keywords for postpartum depression, a sensitive search filter to limit for randomized controlled trials, and a librarian-created "humans" filter. The search results will be uploaded to the Covidence online systematic review platform (Veritas Health Information Ltd., Victoria, Australia) where two review team members will independently screen articles. We will extract data to include year of publication, language, country, participants (number, demographic data, eligibility criteria, psychiatric symptoms, and co-morbidities), characteristics of the intervention and control conditions, and reported outcomes. Risk of bias for each study will be assessed independently by two review authors using the RoB 2: A revised Cochrane risk of bias tool for randomized trials. Network meta-analysis will be performed using a Bayesian hierarchical model supplemented with a Markov chain Monte Carlo approach.

DISCUSSION

Postpartum depression is a devastating disease with long-lasting consequences. Given the numerous available interventions to both prevent and treat postpartum depression and the great number of studies comparing them, it is imperative that clinicians and patients are provided with an assessment of their comparative efficacy and acceptability.

SYSTEMATIC REVIEW REGISTRATION

Prospero registration (CRD42022303247).

Pregnant, miserable, and starving in 21st century America

Severe nausea and vomiting of pregnancy is too common and devastating to be trivialized any longer. Authors of recent studies observed that children exposed in utero to severe nausea and vomiting of pregnancy had an increased risk for autism spectrum disorder, a decreased brain cortical volume, and developmental deficits. Research on severe nausea and vomiting of pregnancy and hyperemesis gravidarum has been disturbingly slow. It was not until 2021 that an international consensus definition was published. Hyperemesis gravidarum starts before 16 weeks' gestation, is characterized by severe nausea with or without vomiting and an inability to eat and drink normally, and greatly limits daily activities. Maternal misery is caused by unrelenting nausea, intractable retching or vomiting, ptyalism, dehydration, reflux, malnutrition, and social isolation. Hyperemesis gravidarum is the second most common reason for hospitalization in pregnancy. Symptoms can persist until delivery in one-third of individuals who experience extreme weight loss. Significant associations have been identified between hyperemesis gravidarum and multiple adverse outcomes. Maternal deaths owing to hyperemesis gravidarum continue to be reported, and hyperemesis gravidarum is associated with high fetal loss and termination rates. These grim findings highlight the critical public health importance of treating severe nausea and vomiting of pregnancy early to mitigate serious complications that compromise maternal and offspring health during pregnancy and beyond. Despite suffering extreme debility, individuals with hyperemesis gravidarum report feeling that their experiences were dismissed by healthcare professionals, contributing to therapeutic termination, suicidal ideation, perinatal depression, and posttraumatic stress disorder. Hyperemesis gravidarum must be recognized early and treated aggressively with frequent monitoring. Although medications can be effective in reducing symptoms, many patients do not gain adequate relief, and new treatments are needed. A promising new avenue for treatment comes from genetic discoveries. The gene, growth differentiation factor-15, which codes for a nausea and vomiting hormone produced by the placenta, is the greatest genetic risk factor for hyperemesis gravidarum, and therapies are currently in clinical trials in cancer. However, until treatment is universally effective, abortion access must be available for refractory hyperemesis gravidarum. Herein, we emphasize data published since the most recent American College of Obstetrics and Gynecology report (2018), such as long-term neuropsychiatric consequences in offspring exposed to hyperemesis gravidarum and suggest interventions anticipated to prevent progression of early symptoms to hyperemesis gravidarum.