Suicidal Ideation During the Postpartum Period

Universal screening of postpartum depression with Edinburgh Postpartum Depression Scale: A prospective observational study

OBJECTIVES

To assess the feasibility of universal screening of postpartum depression (PPD), using the Edinburgh Postpartum Depression Scale (EPDS) in the general population. To investigate the proportion of women identified as being at risk of PPD and with confirmed PPD or other mental disorders after a psychiatric consultation.

METHODS

A multicenter prospective cohort study in four French maternities conducted between 2020 and 2023. All women aged over 18 years, who delivered following a singleton pregnancy after 37 weeks of gestation were eligible for inclusion. The exclusion criteria were pre-existing psychiatric disorders such as depressive syndrome. The EPDS was completed at 8 weeks postpartum via an online self-administered questionnaire. If the response to the questionnaire suggested a mental disorder, a psychiatric consultation was proposed to the women concerned. The endpoints were the proportion of women completing the EPDS, the EPDS score, the proportion of women at risk of PPD, the proportion of psychiatric consultation, and the subsequent diagnosis.

RESULTS

The study included 923 women, of whom 55.0% (508/923) completed the EPDS. Among them, 28.1% (143/508) had an EPDS score of 10 or more, and 11.2% (57/508) received a psychiatric consultation. PPD was confirmed in 8.8% (5/57) of women. Other disorders detected were mood disorders, disorders specifically associated with stress, and anxiety/fear-related disorders, in 33.3%, 28.1%, and 14.0% of the women, respectively.

CONCLUSIONS

Screening with self-administered EPDS is feasible, with a good response rate, making it possible to suspect mental disorders, including PPD, and to offer psychological support when needed.

Antenatal anxiety symptoms outperform antenatal depression symptoms and suicidal ideation as a risk factor for postpartum suicidal ideation

BACKGROUND AND OBJECTIVES

Suicidal ideation (SI) during the postpartum phase is linked with suicide, a leading cause of death during this period. Antenatal depression and anxiety symptoms have both been linked with increased risk for postpartum SI. However, research aimed at examining the relative contributions of antenatal anxiety and depression symptoms towards postpartum SI remains nascent. In this study, we investigated the relative contribution of antenatal anxiety symptoms, depression symptoms, and SI towards postpartum SI.

DESIGN

These data are from a longitudinal study in which American mothers were assessed during pregnancy and again at six- to eight weeks postpartum.

METHODS

Data were analyzed using correlations and logistic regression models.

RESULTS

Antenatal anxiety symptoms and antenatal depression symptoms were significantly correlated with postpartum SI. Results from a logistic regression model indicated that antenatal anxiety symptoms (T1; OR = 1.185 [1.125, 1.245], p = .004), but not antenatal depression symptoms (T1; OR = 1.018 [0.943, 1.093], p = .812) or antenatal SI (T1; OR = 1.58 [0.11, 22.29], p = 0.73), were significantly associated with postpartum SI.

CONCLUSIONS

Antenatal anxiety symptoms, depression symptoms, and SI were positively associated with postpartum SI. When examined simultaneously, anxiety symptoms during the antenatal phase (but not depression symptoms or SI) predicted SI in the postpartum phase.

Associations Among Lifetime Discrimination Typologies and Psychological Health in Black and Hispanic Women After Birth

OBJECTIVE

To identify lifetime discrimination typologies and examine their associations with psychological health outcomes among Black and Hispanic women after birth.

DESIGN

Secondary analysis of the Community and Child Health Network study data.

PARTICIPANTS

A total of 1,350 Black and 607 Hispanic women.

METHODS

We built two latent class models for Black and Hispanic women using eight indicator variables from different life domains of discrimination (childhood, family, work, police, education, housing, health care, and loans). We used bivariate and multiple regression analyses to examine the association among the identified typologies and postpartum depression and perceived stress at 6 months postpartum.

RESULTS

We selected the three-class model with best fit indices and interpretability: no lifetime discrimination (n = 1,029; 76.22%), high childhood-family racial discrimination (n = 224, 16.59%), and moderate lifetime discrimination (n = 97, 7.19%) among Black women and no lifetime discrimination (n = 493, 81.22%), high childhood-family racial discrimination (n = 93, 15.32%), and high education discrimination (n = 21, 3.46%) among Hispanic women. The adjusted postpartum depression and perceived stress scores were significantly greater in Typologies 2 and 3 than Typology 1 in Black women. The adjusted perceived stress scores were significantly greater in Typologies 2 and 3 than Typology 1 in Hispanic women.

CONCLUSION

Lifetime discrimination experiences manifested in complex patterns. Women who experienced moderate to high discrimination across all or specific life domains had worse postpartum depression and perceived stress at 6 months after birth. It is crucial to address lifetime discrimination to improve maternal mental health.

Use of electroconvulsive therapy during postpartum: A retrospective chart review

Background

There is limited data on use of electroconvulsive therapy (ECT) for management of psychiatric disorders during the postpartum period from India.

Aim

We aimed to assess the demographic and clinical profile of patients receiving ECT during the postpartum period for various psychiatric disorders using a retrospective study design.

Methods

ECT register of the department was reviewed for the period of January 2019 to December 2023 to identify the patients who received ECT during the postpartum period. The treatment records of these patients were evaluated to extract the demographic and clinical profile.

Results

During the study period, 10 patients received ECT during the postpartum period. The mean age of the study sample was 27 (standard deviation [SD]: 2.9) years. Majority of the patients were inpatients (70%) at the time of receiving ECT. Five patients were diagnosed with first-episode depression with postpartum onset, and two patients had postpartum-onset psychotic disorder. One patient was diagnosed with recurrent depressive episode and one with bipolar disorder, current episode mania with psychotic symptom, at the time of receiving ECT. The mean number of ECTs during the ECT course was 6.7 (SD: 3.09). Nine out of the 10 patients showed good response to ECT.

Conclusion

Although ECT is less frequently used for management of postpartum psychiatric disorders, its use is associated with significant clinical improvement.

Maternal Psychological Symptom Trajectories From 2 to 24 Months Postpartum: A Latent Class Growth Analysis

BACKGROUND

Postpartum women experience an array of psychological symptoms that are associated with adverse health behaviors and outcomes including postpartum suicidal ideation and long-term depression. To provide early management of postpartum psychological symptoms, it is important to understand how the symptom experiences change over time.

OBJECTIVE

The aim of this study was to examine maternal psychological symptom trajectories over 2, 6, 15, and 24 months postpartum using latent class growth analysis and to examine how each trajectory is associated with maternal depression outcome at 24 months.

METHODS

We used secondary data from the Family Life Project ( N = 1,122) and performed multitrajectory latent class growth analysis based on four observed symptom variables (depression, anxiety, somatization, and hostility). After the final model was identified, bivariate analyses were conducted to examine the association between each trajectory and (a) individual characteristics and (b) outcome (Center for Epidemiologic Studies Depression Scale [CES-D]) variables.

RESULTS

A four-class model was selected for the final model because it had better fit indices, entropy, and interpretability. The four symptom trajectories were (a) no symptoms over 24 months, (b) low symptoms over 24 months, (c) moderate symptoms increasing over 15 months, and (d) high symptoms increasing over 24 months. More postpartum women with the trajectory of high symptoms increasing over 24 months (Trajectory 4) were in low economic status (92.16%), unemployed (68.63%), or did not complete 4-year college education (98.04%). Most postpartum women (95.56%) in Trajectory 4 also had higher CES-D cutoff scores, indicating a possible clinical depression at 24 months postpartum.

DISCUSSION

Postpartum women who experience increasing symptom trajectories over 15-24 months (Trajectories 3 and 4) could benefit from tailored symptom management interventions provided earlier in the postpartum period to prevent persistent and worsening symptom experiences.

Working with suicidal mothers during the perinatal period: a reflexive thematic analysis study with mental health professionals

BACKGROUND

Suicide is the leading cause of death in mothers postpartum and one of the most common causes of death during pregnancy. Mental health professionals who work in perinatal services can offer insights into the factors they perceive as being linked to mothers' suicidal ideation and behaviour, support offered to mothers and improvements to current practices. We aimed to explore the experiences and perceptions of perinatal mental health professionals who have worked with suicidal mothers during the perinatal period.

METHOD

Semi-structured interviews were conducted face-to-face or via telephone with mental health professionals working in perinatal mental health inpatient or community services across England. Data were analysed using reflexive thematic analysis.

RESULTS

From the professionals' (n = 15) accounts three main themes were developed from their interview data. The first, factors linked to suicidal ideation and behaviour, overarched two sub-themes: (1.1) the mother's context and (1.2) what the baby represents and what this means for the mother. These sub-themes described factors that professionals assessed or deemed contributory in relation to suicidal ideation and behaviour when a mother was under their care. The second main theme, communicating about and identifying suicidal ideation and behaviour, which outlined how professionals enquired about, and perceived, different suicidal experiences, encapsulated two sub-themes: (2.1) how to talk about suicide and (2.2) types of suicidal ideation and attempts. The third main theme, reducing suicidal ideation through changing how a mother views her baby and herself, focused on how professionals supported mothers to reframe the ways in which they viewed their babies and in turn themselves to reduce suicidal ideation.

CONCLUSION

Professionals highlighted many factors that should be considered when responding to a mother's risk of suicide during the perinatal period, such as the support around her, whether the pregnancy was planned and what the baby represented for the mother. Professionals' narratives stressed the importance of adopting a tailored approach to discussing suicidal experiences with mothers to encourage disclosure. Our findings also identified psychological factors that professionals perceived as being linked to suicidal outcomes for mothers, such as self-efficacy; these factors should be investigated further.

Self-harm thoughts among postpartum women - associated factors

BACKGROUND

Even though in many countries suicide is the leading cause of maternal deaths during the postpartum period, the prevalence of thoughts of self-harm (SHTs), an important risk factor for suicide attempts, is still not well documented.

AIM

We aimed to investigate the prevalence of SHTs in a Polish cohort of postpartum women and identify socio-demographic and maternal mental health factors associated with experiencing SHTs.

METHOD

1545 women took part in a midwife-led postpartum depression (PPD) screening. 337 of them reported SHTs. The Edinburgh Postpartum Depression Scale (EPDS) was administered. Specifically, we used an abbreviated 5-item version to assess depression symptoms, item 10 to assess SHTs, a composite score of items 1 and 2 - anhedonia, and a composite score of items 3, 4, and 5 - anxiety. Logistic regression analyses were performed to examine associations between variables.

RESULTS

Approximately 2% (n = 337) of women self-reported experiencingSHTs. Within the group of postpartum mothers who self-reported SHTs, 65.60% (n = 221) manifested the symptoms of PPD, and 56.40% (n = 190) - of anxiety. The symptoms of PPD, a mood disorder diagnosed in the past, and younger age were predictors of SHTs.

CONCLUSION

The results of this study can contribute to the development of prevention strategies: analysing separately items from PPD screening questionnaires focusing on SHTs can be an important part of prevention. The lack of the symptoms of PPD and anxiety risk does notexclude experiencing SHTs.

The cost-effectiveness of zuranolone versus selective serotonin reuptake inhibitors for the treatment of postpartum depression in the United States

AIMS

The objective of this research is to evaluate the cost-effectiveness of zuranolone, the first oral treatment indicated for postpartum depression (PPD) in adults approved by the United States Food and Drug Administration.

METHODS

Zuranolone and selective serotonin reuptake inhibitor (SSRI) trial-based efficacy was derived from an indirect treatment comparison. Long-term efficacy outcomes were based on a large longitudinal cohort study. Maternal health utility values were derived from trial-based, short-form 6-D responses. Other inputs were derived from literature and economic data from the US Bureau of Labor Statistics. We estimated costs (2023 US dollars) and quality-adjusted life-years (QALYs) for patients with PPD treated with zuranolone (14-day dosing) or SSRIs (chronic dosing). The indirect costs and QALYs of the children and partners were also estimated.

RESULTS

The incremental cost-effectiveness ratio for zuranolone versus SSRIs was $94,741 per QALY gained over an 11-year time horizon. Maternal total direct medical costs averaged $84,318 in the zuranolone arm, compared to $86,365 in the SSRI arm. Zuranolone-treated adults averaged 6.178 QALYs compared to 6.116 QALYs for the SSRI arm. Costs and utilities for the child and partner were also included in the base case. Drug and administration costs for zuranolone averaged $15,902, compared to $30 for SSRIs over the studied time horizon. Results were sensitive to the model time horizon.

LIMITATIONS

As head-to-head trials were not available to permit direct comparison, efficacy inputs were derived from an indirect treatment comparison which can be confounded by cross-trial differences. The data used are reflective of a general PPD population rather than marginalized individuals who may be at a greater risk for adverse PPD outcomes. The model likely excludes unmeasured effects for patient, child, and partner.

CONCLUSIONS

This economic model's results suggest that zuranolone is a more cost-effective therapy compared to SSRIs for treating adults with PPD.

Screening for postpartum depression and risk of suicidality with obstetrical patients: a cross-sectional survey

BACKGROUND

Pregnancy is a vulnerable time where the physical and social stress of the COVID-19 pandemic affects psychological health, including postpartum depression (PPD). This study is designed to estimate the prevalence and correlates of PPD and risk of suicidality among individuals who gave birth during the COVID-19 pandemic.

METHODS

We surveyed individuals who gave birth at The Ottawa Hospital and were ≥ 20 days postpartum, between March 17 and June 16, 2020. A PPD screen consisted of a score ≥ 13 using the Edinburgh Postnatal Depression Scale. A score of 1, 2, or 3 on item 10 ("The thought of harming myself has occurred to me") indicates risk of suicidality. If a participant scores greater than ≥ 13 or ≥ 1 on item 10 they were flagged for PPD, the Principal Investigator (DEC) was notified within 24 h of survey completion for a chart review and to assure follow-up. Modified Poisson multivariable regression models were used to identify factors associated with PPD and risk of suicidality using adjusted risk ratios (aRR) and 95% confidence intervals (CI).

RESULTS

Of the 216 respondents, 64 (30%) screened positive for PPD and 17 (8%) screened positive for risk of suicidality. The maternal median age of the total sample was 33 years (IQR: 30-36) and the infant median age at the time of the survey was 76 days (IQR: 66-90). Most participants reported some form of positive coping strategies during the pandemic (97%) (e.g. connecting with friends and family, exercising, getting professional help) and 139 (64%) reported negative coping patterns (e.g. over/under eating, sleep problems). In total, 47 (22%) had pre-pregnancy anxiety and/or depression. Negative coping (aRR:2.90, 95% CI: 1.56-5.37) and pre-existing anxiety/depression (aRR:2.03, 95% CI:1.32-3.11) were associated with PPD. Pre-existing anxiety/depression (aRR:3.16, 95% CI:1.28-7.81) was associated with risk of suicidality.

CONCLUSIONS

Almost a third of participants in this study screened positive for PPD and 8% for risk of suicidality. Mental health screening and techniques to foster positive coping skills/strategies are important areas to optimize postpartum mental health.

Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care

OBJECTIVE

The goal of this study was to examine the association between self-reported social needs and postpartum depression (PPD) symptoms of mothers screened in pediatric primary care clinics.

METHODS

This retrospective cohort study used electronic health record data from 3616 pediatric patients (age 0-6 months), whose mothers completed the Edinburgh Postpartum Depression Scale (EPDS) and a social needs screening in a large pediatric primary care network between April 2021 and February 2022. Mothers were screened for four self-reported social needs (food, housing, transportation, and utilities). Logistic regression evaluated the association between the report of any social need and a positive EPDS screen (≥ 10), adjusting for demographic and clinical characteristics and ZIP code-level poverty.

RESULTS

Overall, 8.6% of mothers screened positive for PPD and 10.0% reported any social needs. The odds of a positive depression screen were significantly higher among mothers who reported any social need compared to those not reporting a social need (OR 4.18, 95% CI 3.11-5.61). The prevalence of all depressive symptoms on the EPDS was significantly higher among those who reported any social need, relative to those reporting no needs. Mothers reporting any social needs were significantly more likely to report thoughts of self-harm (6.9% vs 1.5%, P < .005).

CONCLUSIONS

Self-report of social need was significantly associated with positive PPD screens during infant well-child visits. Social needs may be a target of future interventions addressing PPD in pediatric settings. Improving care for social needs may have added benefit of alleviating the risk of PPD.

Difficulties experienced by health care professionals who performed home visits to screen for postpartum depression during the COVID-19 pandemic: a qualitative study in Japan

BACKGROUND

Postpartum depression is a risk factor for suicide and maltreatment of children, and its early detection and appropriate intervention are issues to be resolved. In Japan, local governments are working to detect postpartum depression early by conducting home visits to families with infants within 4 months postpartum, but home-visit professionals have faced new difficulties due to the coronavirus disease 2019 (COVID-19) pandemic that started in 2020. The purpose of this study was to clarify the difficulties experienced by health care professionals who perform home visits to screen for postpartum depression.

METHODS

Focus-group interviews were conducted during the COVID-19 pandemic with health care professionals (n = 13) who make postpartum home visits to families with infants within 4 months. Data were analyzed using thematic analysis.

RESULTS

Four main categories were identified that describe the difficulties experienced by health care professionals: "Lack of support for partners," "Difficulty in talking face-to-face," "Inability to offer family assistance," and "Anxiety about being a source of infection."

CONCLUSIONS

This study shed light on the difficulties faced by professionals in supporting mothers and children in the community during the COVID-19 pandemic. Although these difficulties were considered to have become apparent during the pandemic, the results may offer an important perspective for postpartum mental health support even after the pandemic ends. Accordingly, it may be necessary for these professionals to receive supported through multidisciplinary collaboration in order to improve postpartum care in the community.

The effect of emotional support on postpartum depression among postpartum mothers in Asia: A systematic review

INTRODUCTION

Postpartum depression (PPD) is a chronic mood illness that typically develops in the first few months after giving birth. It affects 17.2% of women worldwide, and its deleterious consequences on infants, children, and mothers have elicited global public concern. Therefore, this paper aims to present an overview of the relationship between emotional support and PPD among postpartum mothers in the Asia region.

METHODS

An extensive search using various keywords was conducted in Science Direct, PsycINFO, PubMed, Scopus, Cochrane Library, JSTOR, Springer Link, and Taylor Francis. The screening process was compliant with the PRISMA guideline, while the quality of the selected studies was assessed using the QuADS tool.

RESULTS

The analysis included 15 research from 12 different countries with 6031 postpartum mothers. A decreased risk of PPD for postpartum mothers is shown to be significantly correlated with greater emotional support, and vice versa.

DISCUSSION

Asian women are less likely to seek emotional assistance than other mothers, which is influenced by culture. There needs to be more research on the impact of culture on postpartum mothers' emotional support. Additionally, this review hopes to raise awareness among the mothers' friends and family as well as the medical community to be more attentive to postpartum mothers' emotional needs and offer specialized assistance.

A Randomized Controlled Trial of Listening Visits for Mothers of Hospitalized Newborns

BACKGROUND

Emotional distress is frequently experienced by mothers whose newborns are hospitalized in a neonatal intensive care unit (NICU). Among these women, there is a critical need for emotional support conveniently delivered at the newborn's point of care by a trusted and medically knowledgeable professional: a NICU nurse. One promising way to enhance in situ delivery of emotional care is to have a NICU nurse provide Listening Visits (LVs), a brief support intervention developed expressly for delivery by nurses to depressed postpartum women.

OBJECTIVES

This trial assessed the feasibility of having NICU nurses deliver LVs to emotionally distressed mothers of hospitalized newborns and compared depression outcomes in a small sample of participants randomized to LVs or usual care (UC).

METHODS

In this pilot randomized controlled trial, emotionally distressed mothers of hospitalized newborns were randomized to receive up to six LVs from a NICU nurse or UC from a NICU social worker. To assess change in depression symptoms, women were invited to complete the Inventory of Depression and Anxiety Symptoms-General Depression Scale at enrollment and 4 and 8 weeks post-enrollment.

RESULTS

Depression symptoms declined over time for both groups, with no difference between the two groups. A post hoc analysis of reliable change found higher rates of improvement at the 4-week assessment among recipients of LVs than UC.

DISCUSSION

NICU nurses successfully implemented LVs during this trial. Depression symptom scores did not significantly differ in the two groups posttreatment or at follow-up. Nevertheless, post hoc analyses indicated comparatively higher rates of clinical improvement immediately after LVs, suggesting the intervention can reduce maternal depression early on when women are most distressed.

Adverse Perinatal Outcomes and Postpartum Suicidal Behavior in California, 2013-2018

Background: The objectives of this study were to describe trends in the prevalence of postpartum suicidal behaviors in California, 2013-2018, and to estimate associations between adverse perinatal outcomes and suicidal behaviors. Materials and Methods: We used data from a population-based cohort derived from all birth and fetal death certificates. Records were individually linked to maternal hospital discharge records for the years before and after delivery. We estimated the prevalence of postpartum suicidal ideation and attempt by year. Then, we estimated crude and adjusted associations between adverse perinatal outcomes and these suicidal behaviors. The sample included 2,563,288 records. Results: The prevalence of postpartum suicidal ideation and attempt increased from 2013 to 2018. People with postpartum suicidal behavior were younger, had less education, and were more likely to live in rural areas. A greater proportion of those with postpartum suicidal behavior were Black and publicly insured. Severe maternal morbidity, neonatal intensive care unit admission, and fetal death were associated with greater risk of ideation and attempt. Major structural malformation was not associated with either outcome. Conclusions: The burden of postpartum suicidal behavior has increased over time and is unequally distributed across population subgroups. Adverse perinatal outcomes may help identify individuals that could benefit from additional care during the postpartum period.

Telehealth Listening Visits for emotionally distressed mothers of hospitalized newborns: Proof-of-concept

Problem

Newborn admission to the neonatal intensive care unit (NICU) is stressful. Yet in clinical practice, at best, NICU mothers are screened for depression and if indicated, referred to a mental-health specialist. At worst, no action is taken. Listening Visits, an empirically supported nurse-delivered intervention addressing emotional distress, can be conveniently provided by a NICU nurse. Prompted by the need to minimize face-to-face contacts during the pandemic, the primary purpose of this small pilot trial was to assess the feasibility of having nurses provide Listening Visits to NICU mothers over Zoom. Secondarily, we assessed pre-to post-Listening Visits depression symptom scores as a preliminary evaluation of the effectiveness of this type of support.

Materials and methods

Nine NICU mothers with mildly to moderately severe depression symptoms received up to six Listening Visits sessions from a NICU nurse via Zoom. Participants completed the Inventory Depression and Anxiety Symptoms-General Depression scale (IDAS-GD) at study entry and 4- and 8-weeks post enrollment. They completed the Client Satisfaction Questionnaire (CSQ) at the 8-week assessment.

Results

Using an intent-to-treat approach, the effect of time from the mixed model analysis of IDAS-GD was statistically significant (F(2,26) = 10.50, p < 0.001), indicating improvement in IDAS-GD scores from baseline to follow-up. The average CSQ score was high (M = 29.0, SD = 3.3), with 75% of participants rating the quality of help they received as "excellent".

Discussion

In this pilot trial, we learned it is feasible to provide Listening Visits over Zoom, that this mode of delivery is associated with a significant decrease in depression symptom scores, and that women value this approach.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [#201805961].

Women with perinatal suicidal ideation–A scoping review of the biopsychosocial risk factors to inform health service provision and research

Objectives

This review aims to map the existing evidence on perinatal suicidal ideation, identify biopsychosocial risk factors associated with suicidal ideation and make recommendations for service provision and future research.

Methods

Scoping review guided by Arskey’s and O’Malley’s (2005) framework. Five academic databases (PsycINFO, MEDLINE, CINAHL, ASSIA and Academic Search Complete) were searched from 1^st January 2009 to 1^st April 2022. Studies were screened by title, abstract and full text against inclusion and exclusion criteria. Primary qualitative, quantitative and mixed-methods studies, written in English pertaining to perinatal suicidal ideation were included. Forty-one studies met the eligibility criteria, data were extracted and narratively synthesised. Findings are reported in accordance with the PRISMA-SR extension.

Key conclusions

Findings were mapped onto the biopsychosocial framework and include sleep deprivation, maternal age, pregnancy complications, mood disorders, intimate partner violence, childhood maltreatment/abuse, low socioeconomic status, alcohol and tobacco misuse, miscarriage/perinatal loss, birth trauma and sleep deprivation. The findings demonstrate that the biopsychosocial risk factors for perinatal suicidal ideation are varied and complex.

Implications for practice

The minimisation of women’s experiences may lead to detrimental consequences and there is a need for increased knowledge of mental health problems by those working with women in the perinatal period to ensure safety planning conversations occur with every woman meeting ‘at risk’ criteria.

[Mother's experience of planned caesarean section in the absence of the father or companion: Impact of Covid-19 pandemic-related lockdown]

BACKGROUND

The presence of the father or companion during planned caesarean section presents several benefits. However, we found no study regarding the mother's experience of his presence or absence.

MATERIAL AND METHODS

We conducted an observational, prospective, two-centre study based on the data of women who had a planned caesarean section in Bel Air and Mercy Maternities between November 17th 2020 and June 4th 2021. Two groups were formed : a control group, including women who had a c-section in the presence of the father or companion, and a case group, including women who had a c-section without the father or companion due to Covid-19 pandemic-related containment measures. The primary endpoint was to assess the mother's anxiety regarding the presence or absence of the father or companion during planned c-section, by the use of a numerical scale of stress and STAI YA inventory. The secondary endpoint was the appraisal of information given by the medical team concerning c-section and the containment measures.

RESULTS

Regarding the level of stress during the c-section, we did not find a significant difference by the use of the numerical scale of stress. With a mean of 53 in the case group and 49 in the focus group (P=0,048), the STAI YA scores showed a significant difference. Between the day before and the day of the c-section, we found no significant difference by the use of the numerical scale of stress. STAI YA scores showed a significant difference, with a delta of 5 in the case group against 1 in the focus group (P=0,01). Most patients estimated that the information given by the medical team helped to reduce their stress. 93 % of the patients in the focus group reckoned they would have been more stressed in the absence of the father or companion.

DISCUSSION AND CONCLUSION

The significant results of this study suggest the absence of the father or companion during planned caesarean section has an impact on mother's experience. Therefore, this should be considered in order to better our practices and improve mother's experience. In the long term, we could imagine making their presence possible during emergency caesarean sections as well (general anesthesia excluded). We could also envision adding to preparation courses to c-section to birth preparation courses, for mothers (to reduce psychological impact) but also for fathers or companions (to allow their presence in the operation room).

Racial and Ethnic Disparities in Postpartum Care in the Greater Boston Area During the COVID-19 Pandemic

IMPORTANCE

Racial and ethnic disparities in postpartum care access have been well identified in the United States. Such disparities could be exacerbated by the COVID-19 pandemic because of amplified economic distress and compromised social capital among pregnant women who belong to racial or ethnic minority groups.

OBJECTIVE

To examine whether the COVID-19 pandemic is associated with an increase in the existing racial and ethnic disparity in postpartum care access.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study using electronic health records data. Multinomial logistic regressions in an interrupted time series approach were used to assess monthly changes in postpartum care access across Asian, Hispanic, non-Hispanic Black (hereafter, Black), non-Hispanic White (hereafter, White) women, and women of other racial groups, controlling for maternal demographic and clinical characteristics. Eligible participants were women who gave live birth at 8 hospitals in the greater Boston, Massachusetts, area from January 1, 2019, to November 30, 2021, allowing for tracking 90-day postpartum access until March 1, 2022.

EXPOSURES

Delivery period: prepandemic (January to December 2019), early pandemic (January to March 2020), and late pandemic (April 2020 to November 2021).

MAIN OUTCOMES AND MEASURES

Postpartum care within 90 days after childbirth was categorized into 3 groups: attended, canceled, and nonscheduled.

RESULTS

A total of 45 588 women were included. Participants were racially and ethnically diverse (4735 [10.4%] Asian women, 3399 [7.5%] Black women, 6950 [15.2%] Hispanic women, 28 529 [62.6%] White women, and 1269 [2.8%] women of other race or ethnicity). The majority were between 25 and 34 years of age and married and had a full-term pregnancy, vaginal delivery, and no clinical conditions. In the prepandemic period, the overall postpartum care attendance rate was 75.2%, dropping to 41.7% during the early pandemic period, and rebounding back to 60.9% in the late pandemic period. During the months in the late pandemic, the probability of not scheduling postpartum care among Black (average marginal effect [AME], 1.1; 95% CI, 0.6-1.6) and Hispanic women (AME, 1.3; 95% CI, 0.9-1.6) increased more than among their White counterparts.

CONCLUSIONS AND RELEVANCE

In this cohort study of postpartum care access before and during the COVID-19 pandemic, racial and ethnic disparities in postpartum care were exacerbated following the onset of the COVID-19 pandemic, when postpartum care access recovered more slowly among Black and Hispanic women than White women. These disparities require swift attention and amelioration to address barriers for these women to obtain much needed postpartum care during this pandemic.

Maternal Suicide Ideation and Behaviour During Pregnancy and the First Postpartum Year: A Systematic Review of Psychological and Psychosocial Risk Factors

Suicide is a leading cause of maternal death during pregnancy and up to a year after birth (perinatal period). Many psychological and psychosocial risk factors for maternal suicidal ideation and behaviour have been investigated. Despite this, there have been no attempts to systematically search the literature on these risk factors. Additionally, few studies have described how the risk factors for suicidal ideation, attempted suicides and suicide deaths differ, which is essential for the development of tools to detect and target suicidal ideation and behaviour. Seven databases were searched up to June 2021 for studies that investigated the association between suicidal ideation and/or suicidal behaviour and psychological/psychosocial risk factors in pregnant and postpartum women. The search identified 17,338 records, of which 59 were included. These 59 studies sampled a total of 49,929 participants and investigated 32 different risk factors. Associations between abuse, experienced recently or during childhood, and maternal suicide ideation, attempted suicide and death were consistently reported. Social support was found to be less associated with suicide ideation but more so with suicide attempts. Identifying women who have experienced domestic violence or childhood abuse and ensuring all women have adequate emotional and practical support during the perinatal period may help to reduce the likelihood of suicidal behaviour.

Timing of perinatal mental health needs: data to inform policy

BACKGROUND

The policies pertaining to perinatal healthcare should be informed by medical needs. The windows of standard obstetrical care and mandated Medicaid coverage eligibility typically end approximately 8 weeks postpartum, even though women may have perinatal health concerns, including suicidal ideation, which are identified beyond this period.

OBJECTIVE

To evaluate the timing of mental health needs across the perinatal period with a focus on how frequently the initial referral and suicidal ideation occur outside of standard obstetrical care windows.

STUDY DESIGN

This retrospective cohort study included all women during pregnancy or up to one year postpartum referred to a perinatal mental health collaborative care program (COMPASS) between September 2017 and September 2019. The timing of initial referral to COMPASS was identified, with women referred postpartum categorized by whether the referral was made after 8 weeks postpartum. The characteristics of the women were compared according to the timing of the initial mental health referral with receiver operating characteristic curves to identify whether patient characteristics could accurately classify women whose initial mental health needs were not recognized until after 8 weeks postpartum. Similarly, the assessment of suicidal ideation, either at or after referral, was ascertained, with the evaluation of the timing at which suicidal ideation was first expressed.

RESULTS

Of 1421 women referred for mental healthcare during the study period, 774 (54%) were initially referred antenatally and 647 (46%) were initially referred postpartum. The women who were referred antenatally exhibited no clustering in the timing of referral. Of the women referred postpartum, 203 (31%) were referred after 8 weeks postpartum. Sociodemographic and medical characteristics were unable to accurately classify which women were referred for mental health care after 8 weeks postpartum (area under the curve, 0.64; 95% confidence interval, 0.58-0.68). A total of 215 (16%) women reported suicidal ideation at or after the time of initial referral: 129 (17%) antenatally and 86 (14%) postpartum. The incidence of suicidal ideation was not significantly different before vs 8 weeks postpartum.

CONCLUSION

Perinatal mental health needs, including suicidal ideation, are often first recognized beyond 8 weeks postpartum. These data should be taken into consideration in policymaking discussions pertaining to the approach to medical care continuity and postpartum healthcare coverage.

Comparative evaluation of the impact of the COVID-19 lockdown on perinatal experience: a prospective multicentre study

OBJECTIVES

To compare in the early postpartum the perinatal experience during a COVID-19 related lockdown ("lockdown" group) and a pandemic control group subject to looser restrictions.

DESIGN & SETTING

This national multicentre prospective cohort study took place in four French maternity units.

POPULATION

Women were recruited during the postpartum stay for the lockdown and pandemic control groups, according to their enrolment period. Both faced the same labour and delivery restrictions, but only the pandemic control group could have a postpartum visitor.

MAIN OUTCOME MEASURES

The primary outcome was the perinatal experience during childbirth, assessed by the Labour Agentry Scale (LAS) self-administered questionnaire, completed before discharge.

RESULTS

The study included 596 women and analysed 571: 260 in the lockdown group and 311 in the pandemic control group. The mean LAS score was lower in the lockdown group (161.1 ± 26.8, 95% confidence interval [CI] 157.8-164.3 versus 163.3 ± 24.0, 95% CI 160.6-166.0; P=0.289). In multivariable analysis, the LAS score was lower in the lockdown group (-6.2 points, P= 0.009), in women with caesarean (-21.6 points, P<0.001) versus spontaneous deliveries, and among women financially impacted by the lockdown (-6.4 points, P=0.007) or who experienced restrictions during childbirth (-8.1 points, P<0.001). The LAS score rose with the prenatal care quality score (P<0.001).

CONCLUSIONS

The perinatal experience was more negatively affected by lockdown restrictions than by the looser pandemic restrictions for controls, but mode of delivery remained the main factor influencing this experience.

Postpartum depression and suicide in Iran

In Iran, postpartum depression is one of the common emotional symptoms which affects approximately 25% of the women who experienced childbirth. Iranian Forensic Medicine Organization (IFMO) and its branches across the country are the comprehensive sources of collecting data related to suicide deaths. In the data collecting form of suicide, there is not any item about the pregnancy of women at the time of suicide, having childbirth during the previous six weeks, and the time interval between delivery and suicide. It is suggested that, in addition to modifying the suicide registration forms by the IFMO, attention should be given to developing a mechanism that gives forensic physicians access to medical records information in the integrated health system as well as hospital information system.

Effect of Zuranolone vs Placebo in Postpartum Depression: A Randomized Clinical Trial

Importance

Postpartum depression (PPD) is one of the most common medical complications during and after pregnancy, negatively affecting both mother and child.

Objective

To demonstrate the efficacy and safety of zuranolone, a neuroactive steroid γ-aminobutyric acid receptor-positive allosteric modulator, in PPD.

Design, Setting, and Participants

This phase 3, double-blind, randomized, outpatient, placebo-controlled clinical trial was conducted between January 2017 and December 2018 in 27 enrolling US sites. Participant were women aged 18 to 45 years, 6 months or fewer post partum, with PPD (major depressive episode beginning third trimester or ≤4 weeks postdelivery), and baseline 17-item Hamilton Rating Scale for Depression (HAMD-17) score of 26 or higher. Analysis was intention to treat and began December 2018 and ended March 2019.

Interventions

Randomization 1:1 to placebo:zuranolone, 30 mg, administered orally each evening for 2 weeks.

Main Outcomes and Measures

Primary end point was change from baseline in HAMD-17 score for zuranolone vs placebo at day 15. Secondary end points included changes from baseline in HAMD-17 total score at other time points, HAMD-17 response (≥50% score reduction) and remission (score ≤7) rates, Montgomery-Åsberg Depression Rating Scale score, and Hamilton Rating Scale for Anxiety score. Safety was assessed by adverse events and clinical assessments.

Results

Of 153 randomized patients, the efficacy set comprised 150 patients (mean [SD] age, 28.3 [5.4] years), and 148 (98.7%) completed treatment. A total of 76 patients were randomized to placebo, and 77 were randomized to zuranolone, 30 mg. Zuranolone demonstrated significant day 15 HAMD-17 score improvements from baseline vs placebo (-17.8 vs -13.6; difference, -4.2; 95% CI, -6.9 to -1.5; P = .003). Sustained differences in HAMD-17 scores favoring zuranolone were observed from day 3 (difference, -2.7; 95% CI, -5.1 to -0.3; P = .03) through day 45 (difference, -4.1; 95% CI, -6.7 to -1.4; P = .003). Sustained differences at day 15 favoring zuranolone were observed in HAMD-17 response (odds ratio, 2.63; 95% CI, 1.34-5.16; P = .005), HAMD-17 score remission (odds ratio, 2.53; 95% CI, 1.24-5.17; P = .01), change from baseline for Montgomery-Åsberg Depression Rating Scale score (difference, -4.6; 95% CI, -8.3 to -0.8; P = .02), and Hamilton Rating Scale for Anxiety score (difference, -3.9; 95% CI, -6.7 to -1.1; P = .006). One patient per group experienced a serious adverse event (confusional state in the zuranolone group and pancreatitis in the placebo group). One patient in the zuranolone group discontinued because of an adverse event vs none for placebo.

Conclusions and Relevance

In this randomized clinical trial, zuranolone improved the core symptoms of depression as measured by HAMD-17 scores in women with PPD and was generally well tolerated, supporting further development of zuranolone in the treatment of PPD.

Trial Registration

ClinicalTrials.gov Identifier: NCT02978326.

Achieving clinical response in postpartum depression leads to improvement in health-related quality of life

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) burden associated with postpartum depression (PPD), determine the extent to which clinical response impacts HRQoL, and estimate the impact of PPD and clinical response on healthcare resource utilization (HRU) and productivity.

METHODS

Patient data (n = 127) from two multicenter, randomized, double-blind, placebo-controlled phase 3 clinical trials evaluating the safety and efficacy of brexanolone injection in adults with PPD were employed for these posthoc analyses. HRQoL and health utility was assessed with the SF-36-v2 Health Survey (SF-36v2) acute version. The 17-item Hamilton Rating Scale for Depression (HAMD-17) total score was used to identify clinical response (≥50% reduction in HAMD-17 total score). Baseline HRQoL burden was assessed by comparison to age- and gender-adjusted population normative data from the 2009 QualityMetric PRO Norming study. The impact of clinical response was evaluated by comparing day 7 and day 30 SF-36v2 scores between clinical responders and non-responders. Interpretations of the meaningfulness of clinical response were indirectly estimated via 2017 National Health and Wellness Survey data linking SF-36v2 mental component summary (MCS) scores to (HRU) and productivity.

RESULTS

Baseline HRQoL of patients with PPD was significantly below normative values. Day 7 and day 30 clinical response were associated with large and statistically significant improvements in HRQoL, greater likelihood of meeting SF-36v2 responder definitions, and reduced impairment. MCS levels corresponding to those observed in clinical responders were linked to lower HRU and productivity loss relative to non-responders.

CONCLUSIONS

PPD places a substantial burden on HRQoL. Achievement of rapid clinical response (at day 7) and clinical response sustained several weeks following the end of treatment (day 30) led to significant improvement in HRQoL, suggesting the importance of identifying women with PPD and providing effective treatment options.

Bibliometrics and Visual Analysis of the Research Status and Trends of Postpartum Depression From 2000 to 2020

The purpose of this study was to evaluate the international scientific output on postpartum depression (PPD) research during 2000–2020 through a bibliometric analysis and to explore research hotspots, frontiers, and trends in the field of postpartum depression. We searched the Web of Science Core Collection for publications on postpartum depression published between 2000 and 2020. CiteSpace, gCluto, and other software applications were used to analyze the data by year, journal, and country. A total of 2,963 publications were retrieved and 96 countries or regions published related papers. The United States had the largest number of published papers and the highest betweenness centrality, which is the dominant position in the field of postpartum depression. A total of 717 journals published papers, with the Archives of Womens Mental Health ranked first in terms of volume and betweenness centrality. In this study, 31 high-frequency main MeSH terms/subheadings were selected. The high-frequency MeSH terms were clustered into six categories: an overview of depression-related research, diagnostic and screening scales for postpartum depression, epidemiological investigation into postpartum depression, treatment and drug selection for postpartum depression, psychological research on postpartum depression, and etiology, physiopathology, complications, genetics of postpartum depression. Finally, we used strategic diagram to analyze research trends in postpartum depression. This study has identified a continuous significant increase in the publication of PPD articles. Currently, the etiology, physiological pathology, intervention and treatment of complications on PPD are immature, which provides reference for the trend of obstetric psychology.

Brexanolone in Postpartum Depression: Post Hoc Analyses to Help Inform Clinical Decision-Making

Background: Brexanolone (BRX) injection was approved by the United States Food and Drug Administration in 2019 for the treatment of adults with postpartum depression (PPD) based on two Phase 3 clinical trials. Materials and Methods: Data from the three trials were combined. PPD-specific 17-item Hamilton Rating Scale for Depression (HAMD-17) group-level minimal important difference (MID) and patient-level meaningful change (meaningful change threshold [MCT]) were estimated and applied to differences in BRX versus placebo (PBO) at hour 60 (primary endpoint) and day 30 (end of trial follow-up). Likelihood of HAMD-17 response and remission and Clinical Global Impression of Improvement (CGI-I) response for BRX versus PBO were assessed at hour 60 and as sustained through day 30 using relative risk. Associated number needed to treat (NNT) and number needed to harm (NNH) values were also estimated. Results: Two-hundred nine patients were included. The average HAMD-17 MID estimate was -2.1; the least-squared mean difference between BRX and PBO exceeded this at hour 60 and day 30. Minimal, moderate, and large MCTs were estimated to be -9, -15, and -20 points, respectively. Significantly more BRX-treated than PBO-treated patients achieved minimal, moderate, and large change (all ps < 0.05) at hour 60 and large meaningful response at day 30 (p < 0.05). BRX-treated patients were more likely to sustain HAMD-17 remission and CGI-I response through day 30 versus PBO. NNTs ranged from 4 to 8, with NNH of 97. Conclusions: BRX provided meaningful changes relative to PBO, rapid (hour 60), and sustained improvements (day 30) in PPD symptoms, low NNT, and large NNH. These results may help inform treatment decision-making. Clinicaltrials.gov registration numbers: NCT02614547, NCT02942004, and NCT02942017.

Birth experience during COVID-19 confinement (CONFINE): protocol for a multicentre prospective study

INTRODUCTION

The absence of companionship during childbirth is known to be responsible for negative emotional birth experience, which can increase the risk of postpartum depression and post-traumatic stress disorder. The context of COVID-19 epidemic and the related confinement could increase the rate of negative experience and mental disorders. The main objective is to compare, in immediate post partum, the maternal sense of control during childbirth between a group of women who gave birth during confinement ('confinement' group) versus a group of women who gave birth after confinement but in the context of epidemic ('epidemic' group) versus a group of control women ('control' group; excluding confinement and epidemic context).

METHODS AND ANALYSIS

This is a national multicentre prospective cohort study conducted in four French maternity units. We expect to include 927 women in a period of 16 months. Women will be recruited immediately in post partum during three different periods constituting the three groups: 'confinement'; 'epidemic' and 'control' group. The maternal sense of control will be evaluated by the Labour Agentry Scale questionnaire completed immediately in post partum. Postnatal depression (Edinburgh Postnatal Depression Scale), post-traumatic stress disorder (Impact of Event Scale-Revised) and breast feeding (evaluative statement) will be evaluated at 2 months post partum.

ETHICS AND DISSEMINATION

The study was approved by the French Ethics Committee, the CPP (Comité de Protection des Personnes) SUD OUEST ET OUTRE-MER IV on 16th of April 2020 with reference number CPP2020-04-040. The results of this study will be published in a peer-reviewed journal and will be presented at relevant conferences.

TRIAL REGISTRATION NUMBER

NCT04348929.

Prevalence and risk factors associated with postnatal depression in a South African primary care facility

BACKGROUND

The prevalence and factors that influence postnatal depression (PND) vary according to context.

AIM

To determine the prevalence and factors associated with PND in the postnatal clinic of a large community health centre.

SETTING

This study was conducted at Levai Mbatha Community healthcare centre, in Evaton, South of Gauteng.

METHOD

In a cross-sectional study, the Edinburg Postnatal Depression Scale (EPDS) was administered on 227 consecutive mothers during postnatal clinic visits. In addition, sociodemographic and clinical information were collected. Analysis included descriptive statistics, chi-square test and logistic regression. A score of greater than 13 on the EPDS screened positive for PND.

RESULTS

Participants' mean age was 27 years, and most completed less than grade 12 education (52.4%), were single (55.5%), were employed or had a working partner (60%) and had no previous PND (97%). The proportion of participants screening positive was 38.8%. In the adjusted logistic regression, completing only primary school education (odds ratio [OR]: 9.11; 95% confidence interval [CI]: 1.03-80.22; p = 0.047), using contraceptive prior to index pregnancy (OR: 2.05; 95% CI: 1.12-3.72; p = 0.019) and reporting a thought of self-harm or infanticide (OR: 7.08; 95% CI: 5.79-22.21; p = 0.000) significantly increased the risk of PND. In contrast, having a relationship with the father of the index child (OR: 0.42; 95% CI: 0.18-0.94; p = 0.037) mitigated this risk.

CONCLUSION

The proportion of women screening positive for PND was high in the study setting and was concomitant with significant risk of suicide or infanticide. This highlights the need to screen and consider PND as a vital sign during postnatal visits, especially in the face of low educational attainment, failed contraception and poor or no relationship with the father of the index child.

The Relationship Between Mother-Child Bonding Impairment and Suicidal Ideation in São Paulo, Brazil

OBJECTIVES

To evaluate the association between mother-child bonding at 6-9 months after birth and suicidal ideation METHODS: A cross-sectional study embedded in a clinical trial with 358 low-income postpartum women who had antenatal depression in São Paulo, Brazil. The Postpartum Bonding Questionnaire and the Patient Health Questionnaire-9 were used RESULTS: The percentage of the main outcome, suicidal ideation (SI) was 10.3%. Using logistic regression models, bonding impairment (BI) was associated with SI even after controlling for postpartum depression and other covariates.

CONCLUSIONS FOR PRACTICE

SI affects 10% of vulnerable postpartum women. BI is independently associated with SI. Treating BI may prevent SI.

Reduced Maternal Serum Total, Free and Bioavailable Vitamin D Levels and its Association with the Risk for Postpartum Depressive Symptoms

BACKGROUND

Low vitamin D levels have been implicated in postpartum depressive disorders. However, studies on bioavailable vitamin D levels in postpartum depression are limited. Our study aimed to assess the serum concentrations of total, free and bioavailable 25-hydroxyvitamin D (25(OH)D) levels in women with postpartum depressive symptoms (PPD) and the association between 25(OH)D levels and PPD at 6 week post-delivery.

METHODS

In this cross-sectional study, a total of 330 cases and 330 age and BMI matched controls were recruited from the tertiary care hospital in South India. Women with depressive symptoms were assessed using the validated Edinburg Postnatal Depression Scale (EPDS) and cut-off score ≥10 was used. Serum 25(OH)D and VDBP levels were measured using commercially available ELISA kits.

RESULTS

Serum total, free and bioavailable 25(OH)D levels were significantly lower in postpartum depressive women compared to non-depressive women (p <0.001, p = 0.01). A significant negative correlation was observed between 25(OH)D, free 25(OH)D and bioavailable 25(OH)D with EPDS score in total study subjects (p <0.001, r = -0.19; p <0.001, r = -0.14 and p <0.001, r = -0.14). Multivariate linear regression analysis further confirmed a significant association between serum total, free and bioavailable 25(OH)D levels and EPDS score (p <0.001∗).

CONCLUSIONS

Our study demonstrated that lower serum total, free and bioavailable 25(OH)D levels were associated with postpartum depressive symptoms. Hypovitaminosis D after delivery may be a risk factor for postpartum depression.

Do Maternal Depression and Self-Esteem Moderate and Mediate the Association Between Intimate Partner Violence After Childbirth and Postpartum Suicidal Ideation?

Intimate partner violence (IPV) during the perinatal period is believed to have an adverse effect on maternal mental health. Given the risks of suicide and related public health concerns, the aim of this study is to examine (1) the association of experiencing physical, psychological, and sexual IPV after childbirth on postpartum suicidal ideation (SI), and (2) whether postpartum depression and self-esteem act to mediate or moderate the relationship between IPV and postpartum SI. A cross-sectional survey was conducted from October 2015 to January 2016 in the Chandpur District of Bangladesh among 426 new mothers, aged 15 to 49 years, who were in the first 6 months postpartum. Multivariate logistic regression models were used to examine the association between experiencing IPV and postpartum SI, controlling for a range of other known influences. The prevalence of postpartum SI was 30.8%. Accounting the influence of other confounders, the odds of postpartum SI were significantly higher among women who reported physical IPV victimization (adjusted odds ratio: 2.65; 95% confidence interval = 1.36, 5.18) at any point during the first 6 months following childbirth as opposed to those who did not. In addition, postpartum depression increased postpartum SI, while high self-esteem significantly reduced reports of SI. Both postpartum depression and maternal self-esteem notably mediate and moderate the effect of physical IPV after childbirth on postpartum SI. The findings illuminate that IPV victimization after childbirth significantly increases the odds of postpartum SI. This study reinforces the need to detect women with a history of IPV who may be at risk for SI, not only to offer them help and support but also to prevent or reduce SI.

Intraoperative ketamine for reduction in postpartum depressive symptoms after cesarean delivery: A double-blind, randomized clinical trial

BACKGROUND

Postpartum depression (PPD) is a common mental disease happens in perinatal period. Ketamine as an anesthesia and analgesia drug has been used for a long time. In recent years, ketamine is proved to have an antidepression effect with a single administration. We hypothesized that intraoperative ketamine can reduce postpartum depressive symptoms after cesarean delivery.

METHODS

In a randomized, double-blind, placebo-controlled study trail, healthy women scheduled for cesarean delivery were randomly assigned to receive intravenous ketamine (0.25 mg/kg diluted to 5 ml with 0.9% saline) or placebo (5 ml of 0.9% saline) within 5 min following clamping of the neonatal umbilical cord. The primary outcome was the degree of postpartum depressive symptoms, which was evaluated by Edinburgh Postnatal Depression Scale (EPDS, a threshold of 9/10 was used) at 1 week, 2 weeks, and 1 month after delivery. The secondary outcome was the numerical rating scale (NRS) score of pain at 2 days postpartum. This trail is registered in the Chinese Clinical Trial Registry, number ChiCTR1900022464.

RESULTS

Between 26 January 2019 and 15 July 2019, 502 subjects were screened and 330 were randomly allocated: 165 (50%) to the ketamine group and 165 (50%) to the placebo group. There were significant differences in the degree of postpartum depressive symptoms between subjects in the ketamine group and the placebo group at 1 week postpartum (13.1% vs. 22.6%, respectively; p = .029). However, no difference was found between subjects in the two groups at 2 weeks (11.8% vs. 16.8%, respectively; p = .209) and 1 month postpartum (10.5% vs. 14.2%, respectively; p = .319). The NRS score of wound pain (3.0 ± 0.9 vs. 4.0 ± 1.0, respectively; p < .001) and uterine contraction pain (3.0 ± 0.9 vs. 4.1 ± 0.9, respectively; p < .001) was lower in the ketamine group at 2 days postpartum compared with placebo group. The prevalence of headache, hallucination, and dizziness was higher in the ketamine group than the placebo group during the operation.

CONCLUSIONS

Operative intravenous ketamine (0.25 mg/kg) can reduce the postpartum depressive symptoms for 1 week. The long-time effect is remained to be seen.

The role of personality dimensions, depressive symptoms and other psychosocial variables in predicting postpartum suicidal ideation: a cohort study

Suicidability has been associated with neuroticism and psychoticism, but its role during perinatal period has not been analyzed. We explore the association between personality dimensions, depressive symptoms, and other psychosocial variables in postpartum suicidal ideation. A cohort of 1795 healthy Spanish women from the general population was assessed for suicidal ideation (EPDS-Item10) in early postpartum, 8 and 32 weeks postpartum. Sociodemographic, obstetric, and reproductive variables, psychiatric history, social support, stressful life-events during pregnancy, depressive symptoms (EPDS), and the Eysenck's personality dimensions (EPQ-RS) were also assessed at baseline. A major depressive episode (DSM-IV) was confirmed in women with EPDS>10 at follow-up assessments. Descriptive, bivariate, and multivariate analyses were conducted. Adjusted logistic regression analysis was reported as odds ratio (ORs) with 95% confidence intervals (CIs). Seven percent of mothers reported suicidal ideation during the first 8 months postpartum. Sixty-two percent of women with suicidal ideation had a major depressive episode at 8 weeks, and 70% at 32 weeks postpartum. Neuroticism and psychoticism predicted suicidal ideation throughout the first 2 weeks after delivery (OR, 1.03; 95%CI 1.01-1.06; and OR, 1.03; 95%CI 1.01-1.05 respectively). Early postpartum depressive symptoms (OR 1.2; 95%CI 1.11-1.26), personal psychiatric history (OR 2.1; 95%CI 1.33-3.27), and stressful life events during pregnancy (OR 1.88; 95%CI 1.12-3.16) also emerged as predictors of postpartum suicidal ideation. Analysis of women for postpartum suicidal ideation should include not only psychiatric symptoms but also psychosocial assessment (i.e., covering psychiatric history, stressful events, or long-standing personality vulnerabilities) in order to identify those in need of early psychosocial or psychiatric care.

Postpartum Depression: When the Stakes Are the Highest

Pregnancy, a sensitive time when two bodies are changing and developing simultaneously, demands careful consideration in assessing and treating mental health conditions. Add to that the restrictions on researching such a vulnerable population, psychiatric nurses face a challenge in providing evidence-based care. The current article focuses on the epidemiology of postpartum depression and long-term consequences, neurobiology of postpartum depression that guides medication selection, and treatment options for supporting postpartum women and their families. [Journal of Psychosocial Nursing and Mental Health Services, 57(11), 9-14.].

The Risk Factors Predicting Suicidal Ideation Among Perinatal Women in Japan

INTRODUCTION

The aim of the present study was to elucidate the foreseeable risk factors for suicidal ideation among Japanese perinatal women.

METHODS

This cohort study was conducted in Nagoya, Japan, from July 2012 to March 2018. The Edinburgh Postnatal Depression Scale (EPDS) questionnaire was conducted at four time points: early pregnancy, late pregnancy, 5 days postpartum, and 1 month postpartum. A total of 430 women completed the questionnaires. A logistic regression analysis was performed using the presence of suicidal ideation on the EPDS as an objective variable. The explanatory variables were age, presence of physical or mental disease, smoking and drinking habits, education, hospital types, EPDS total score in early pregnancy, bonding, and quality and amount of social support, as well as the history of major depressive disorder (MDD).

RESULTS

The rate of participants who were suspected of having suicidal ideation at any of the four time points was 11.6% (n=52), with the highest (n=25, 5.8%) at late pregnancy. For suicidal ideation, education level (OR: 1.19; 95% CI: 1.00-1.41; p=0.047), EPDS total points in the pregnancy period (OR: 1.25; 95% CI: 1.16-1.34; p < 0.000), a history of MDD (OR: 2.16; 95% CI: 1.00-4.79; p=0.049), and presence of mental disease (OR: 2.39; 95% CI: 1.00-5.70; p=0.049) were found to be risk factors for suicidal ideation. Age [odds ratio (OR): 0.88; 95% confidence interval (CI): 0.80-0.95; p=.002] and quality of social support (OR: 0.77; 95% CI: 0.60-0.99; p=.041) were found to be protective factors.

CONCLUSION

Based on these results, effective preventive interventions, such as increasing the quality of social support and confirming the history of depression, should be carried out in pregnant depressive women at the early stage of the perinatal period.

Cost-Effectiveness of Brexanolone Versus Selective Serotonin Reuptake Inhibitors for the Treatment of Postpartum Depression in the United States

BACKGROUND

Brexanolone injection (BRX) was approved by the FDA in 2019 for the treatment of adult patients with postpartum depression (PPD), but its cost-effectiveness has not yet been evaluated.

OBJECTIVE

To estimate the cost-effectiveness of BRX compared with treatment with selective serotonin reuptake inhibitors (SSRIs) for PPD.

METHODS

We projected costs (2018 U.S. dollars) and health (quality-adjusted life-years [QALYs]) for mothers treated with BRX or SSRIs and their children. A health state transition model projected clinical and economic outcomes for mothers based on the Edinburgh Postnatal Depression Scale, from a U.S. payer perspective. The modeled population consisted of adult patients with moderate to severe PPD, similar to BRX clinical trial patients. Short-term efficacy for BRX and SSRIs came from an indirect treatment comparison. Long-term efficacy outcomes over 4 weeks, 11 years (base case), and 18 years were based on results from an 18-year longitudinal study. Maternal health utility values came from analysis of trial-based short-form 6D responses. Other inputs were derived from the literature.

RESULTS

The incremental cost-effectiveness ratio for BRX versus SSRIs was $106,662 per QALY gained over an 11-year time horizon. Drug and administration costs for BRX averaged $38,501, compared with $25 for SSRIs over the studied time horizon. Maternal total direct medical costs averaged $65,908 in the BRX arm, compared with $73,653 in the SSRI arm. BRX-treated women averaged 6.230 QALYs compared with 5.979 QALYs for the SSRI arm. Adding partner costs and utilities in a sensitivity analysis further favored BRX. Results were sensitive to the severity of PPD at baseline and the model time horizon. Probabilistic sensitivity analyses indicated that BRX was cost-effective at the $150,000-per-QALY threshold with 58% probability.

CONCLUSIONS

Analysis using a state transition model showed BRX to be a cost-effective therapy compared with SSRIs for treating women with PPD.

DISCLOSURES

This study was funded by Sage Therapeutics, Cambridge, MA. Eldar-Lissai, Gerbasi, and Hodgkins are employees of Sage Therapeutics and own stock or stock options in the company. Gerbasi also reports previous employment with Policy Analysis Inc. Cohen contributed to this work as an independent consultant. Meltzer-Brody has a sponsored clinical research agreement with Sage Therapeutics to the University of North Carolina, as well as a sponsored research agreement from Janssen to the University of North Carolina, unrelated to this work. Meltzer-Brody has also received personal consulting fees from Cala Health and MedScape, unrelated to this work. Johnson, Chertavian, and Bond are employees of Medicus Economics, which was paid fees by Sage to conduct the research for this study. Study findings do not necessarily represent the views of CEVR or Tufts Medical Center.

Allopregnanolone in postpartum depression: Role in pathophysiology and treatment

Postpartum depression (PPD) is a unique subtype of major depressive disorder and a substantial contributor to maternal morbidity and mortality. In addition to affecting the mother, PPD can have short- and long-term consequences for the infant and partner. The precise etiology of PPD is unknown, but proposed mechanisms include altered regulation of stress response pathways, such as the hypothalamic-pituitary-adrenal axis, and dysfunctional gamma-aminobutyric acid (GABA) signaling, and functional linkages exist between these pathways. Current PPD pharmacotherapies are not directly related to these proposed pathophysiologies. In this review, we focus on the potential role of GABAergic signaling and the GABA_A receptor positive allosteric modulator allopregnanolone in PPD. Data implicating GABAergic signaling and allopregnanolone in PPD are discussed in the context of the development of brexanolone injection, an intravenous formulation of allopregnanolone recently approved by the United States Food and Drug Administration for the treatment of adult women with PPD.

Using Matching-Adjusted Indirect Comparisons and Network Meta-analyses to Compare Efficacy of Brexanolone Injection with Selective Serotonin Reuptake Inhibitors for Treating Postpartum Depression

BACKGROUND

Brexanolone injection, the first therapy approved by the US FDA for the treatment of postpartum depression (PPD) in adults, has been shown to produce a significantly greater decrease in the Hamilton Rating Scale for Depression (HAM-D) total score than placebo in randomised controlled trials (RCTs) of women with PPD.

OBJECTIVES

Given the rapid effect of brexanolone injection (within 60 h) sustained throughout the length of the trials (30 days), we sought to compare its efficacy data against selective serotonin reuptake inhibitors (SSRIs), the class of antidepressants most commonly prescribed for PPD, using HAM-D and Edinburgh Postnatal Depression Scale (EPDS) outcomes from currently available RCTs.

METHODS

We extracted data from 26 studies identified in a systematic literature review of pharmacological and pharmacological/nonpharmacological combination therapies in PPD. Six studies were suitable to form evidence networks through which to perform indirect treatment comparisons (ITCs) of HAM-D and EPDS outcomes between brexanolone and SSRIs. Having assessed the comparability and suitability of the available evidence for analysis, we discovered significant heterogeneity in the study designs, most notably in the placebo arms of the trials. We therefore conducted matching-adjusted indirect comparisons (MAICs) between brexanolone and the placebo arms of comparator studies, subsequently using the MAIC results of brexanolone versus placebo, and results for SSRIs versus placebo, to form ITCs of brexanolone versus SSRIs at three separate time points-day 3, week 4 and last observation. ITCs were calculated as the differences in change from baseline (CFB) in HAM-D and, separately, CFB in EPDS, between treatments, and reported with 95% confidence intervals (CIs).

RESULTS

For all time points, MAICs showed larger differences in CFB for brexanolone compared with SSRIs. Differences (95% CIs) between brexanolone and SSRIs were 12.79 (8.04-17.53) [day 3], 5.87 (- 1.62 to 13.37) [week 4] and 0.97 (- 6.35 to 8.30) [last observation] for the HAM-D. For the EPDS, the differences in CFB were 7.98 (5.32-10.64) [day 3], 6.35 (3.13-9.57) [week 4] and 4.05 (0.79-7.31) [last observation]. Other analytical approaches are also presented to demonstrate the similarity of results, using a network meta-analysis approach, and the importance of using the MAIC method to control for the important heterogeneity between placebo arms.

CONCLUSIONS

Acknowledging the limitations of ITCs and this evidence base, when compared with SSRIs, these analyses suggest that brexanolone demonstrated larger differences in CFB for both patient- and clinician-reported PPD outcomes and at all investigated time points after adjusting for differences between placebos in the included studies.

Strategies to Promote Postpartum Visit Attendance Among Medicaid Participants

Background: Postpartum care is important for promoting maternal and infant health and well-being. Nationally, less than 60% of Medicaid-enrolled women attend their postpartum visit. The Strong Start for Mothers and Newborns II Initiative, an enhanced prenatal care program, intended to improve birth outcomes among Medicaid beneficiaries, enrolled 45,599 women, and included a variety of approaches to increasing engagement in postpartum care. Methods: This study analyzes qualitative case studies that include coded notes from 739 interviews with 1,074 key informants and 133 focus groups with 951 women; 4 years of annual memos capturing activities by each of 27 awardees and 24 Birth Center sites; and a review of interview and survey data from Medicaid officials in 20 states. Results: Strong Start prenatal care included education and support regarding postpartum care and concerns. Key informants identified Strong Start services and other strategies they perceived as increasing access to postpartum care, including provider and/or care coordinator continuity across prenatal, delivery, and postpartum visits; efforts to address information gaps and link women to appropriate resources; enhancing services to meet needs such as treatment for depression; addressing barriers related to transportation and childcare; and aligning incentives to encourage prioritization of postpartum care among patients and providers. They also identified ongoing barriers to postpartum visit attendance. Conclusions: Postpartum care is essential to maternal and infant health. Medicaid enrolls many high-risk women and is the largest payer for postpartum care. Using lessons from Strong Start, providers who serve Medicaid-enrolled women can advance strategies to improve postpartum visit access and attendance.

Combined effect of adverse childhood experiences and young age on self-harm ideation among postpartum women in Japan

BACKGROUND

Suicide among postpartum women is a new and emerging issue in developed countries. However, little is known about the combined effect of risk factors on self-harm ideation, although various risk factors have been found. The aim of this study is to examine the combined effect of maternal adverse childhood experiences and maternal age on self-harm ideation among postpartum women.

METHODS

The study comprised a cross-sectional study of 8074 mothers participating in a 3-month health checkup between September 2013 and August 2014 in City A, Prefecture A, Japan. Main outcome was self-harm ideation assessed using the Edinburgh Postnatal Depression Scale (EPDS), item 10. Possible risk factors were maternal adverse childhood experiences (ACEs), maternal characteristics, relationship with husband/partner (e.g., feelings when pregnancy was confirmed), household characteristics, child characteristics (e.g., age, sex, birth weight), and postpartum characteristics, and postpartum depression status other than self-harm ideation.

RESULTS

Postpartum women with 3 or more ACEs and younger age (<25 years old) were 10.3 times more likely than those with no ACEs and older age to have self-harm ideation (95%CI = 5.3-20.2). This combined effect was also found in first-time mothers (OR = 7.6, 95%CI = 3.2-17.9).

LIMITATIONS

Study limitations are excluding an item on sexual abuse which is one of the ACEs, recall bias and information bias.

CONCLUSIONS

Postpartum women with 3 or more ACEs and who were younger than 25 years old were at a high risk for self-harm ideation. Providing prevention strategies aimed at mothers with multiple risk factors, especially younger age and ACEs, is warranted.

A systematic review of interventions for healthcare professionals to improve screening and referral for perinatal mood and anxiety disorders

Postpartum depression affects approximately 11% of women. However, screening for perinatal mood and anxiety disorders (PMAD) is rare and inconsistent among healthcare professionals. When healthcare professionals screen, they often rely on clinical judgment, rather than validated screening tools. The objective of the current study is to review the types and effectiveness of interventions for healthcare professionals that have been used to increase the number of women screened and referred for PMAD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses was utilized to guide search and reporting strategies. PubMed/Medline, PsychInfo/PsychArticles, Cumulative Index to Nursing, Allied Health Literature (CINAHL), and Health Source: Nursing/Academic Edition databases were used to find studies that implemented an intervention for healthcare professionals to increase screening and referral for PMAD. Twenty-five studies were included in the review. Based on prior quality assessment tools, the quality of each article was assessed using an assessment tool created by the authors. The four main outcome variables were the following: percentage of women screened, percentage of women referred for services, percentage of women screened positive for PMAD, and provider knowledge, attitudes, and/or skills concerning PMAD. The most common intervention type was educational, with others including changes in electronic medical records and standardized patients for training. Study quality and target audience varied among the studies. Interventions demonstrated moderate positive impacts on screening completion rates, referral rates for PMAD, and patient-provider communication. Studies suggested positive receptivity to screening protocols by mothers and providers. Given the prevalence and negative impacts of PMAD on mothers and children, further interventions to improve screening and referral are needed.

Intimate partner violence during pregnancy in relation to non-psychotic mental health disorders in Rwanda: a cross-sectional population-based study

OBJECTIVES

To investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs.

DESIGN

Cross-sectional population-based study conducted in the Northern Province of Rwanda and Kigali city.

PARTICIPANTS AND SETTINGS

Totally, 921 women who gave birth ≤13 months before being interviewed were included. Simple random sampling was done to select villages, households and participants. Community health workers helped to identify eligible participants and clinical psychologists, nurses or midwives conducted face-to-face interviews. The collected data were analysed using descriptive statistics and bivariable and multivariable logistic regression modelling RESULTS: The prevalence rates of generalised anxiety disorder, suicide ideation and post-traumatic stress disorder (PTSD) were 19.7%, 10.8% and 8.0%, respectively. Exposure to the four forms of IPV during pregnancy was highly associated with the likelihood of meeting diagnostic criteria for each of the non-psychotic MHDs investigated. Physical, psychological and sexual violence, showed the strongest association with PTSD, with adjusted ORs (aORs) of 4.5, 6.2 and 6.3, respectively. Controlling behaviour had the strongest association with major depressive episode in earlier periods with an aOR of 9.2.

CONCLUSION

IPV and MHDs should be integrated into guidelines for perinatal care. Moreover, community-based services aimed at increasing awareness and early identification of violence and MHDs should be instituted in all villages and health centres in Rwanda. Finally, healthcare providers need to be educated and trained in a consistent manner to manage the most challenging cases quickly, discreetly and efficiently.

The tip of the iceberg: postpartum suicidality in Israel

Background

Postpartum suicidality, a result of extreme distress or depression, is a tragedy for the woman, infant, and family. Screening for postpartum depression (PPD) is mandatory in Israel, including a question on suicidal ideation. This study presents and analyzes data regarding rates, trends and characteristics of postpartum women who considered, attempted, or completed suicide, to help direct services aimed at preventing these occurrences.

Methods

Suicidal ideation data based on PPD screening was drawn from various publications and databases. Suicide attempt data was obtained from the Emergency Department database for 2006–2015 and matched with the National Birth Registry. Cause of death from the national database for those years were similarly linked to births to identify postpartum suicides and deaths. Postpartum and non-postpartum suicide attempt rates were computed by year, and by age and ethnic/immigrant group. A multivariate logistic model was used to estimate relative risk for postpartum attempts, controlling for age and ethnic group.

Results

Suicidal ideation in recent years has been reported as 1% or less, with higher rates found in studies of Arab women. Suicide attempt rates for non-postpartum women were 3–5 times that of postpartum women, rising over the years, while remaining relatively stable for postpartum women. Adjusted risk of suicide attempt for non-postpartum women was significantly higher; adjusted odds ratio was 4.08 (95% CI 3.75–4.44). It was also significantly higher for Arabs and immigrants from the Former Soviet Union, compared to Israeli-born Jews/veteran immigrants, and for younger women compared to those aged 35–44. Seven postpartum suicides were recorded during 2006–2015, a rate of 0.43 per 100,000 births.

Conclusion

Postpartum suicidality in Israel is low relative to other countries. Although relatively rare and lower than among non-postpartum women, health professionals should be attentive to risk factors, such as past psychiatric disorders, suicide attempts and current emotional distress, particularly among higher-risk populations. The universal screening program for PPD is a valuable opportunity for this, but increased resources should be allotted to implement and utilize it optimally. Prenatal screening should be added as an Israeli Quality Indicator, and postpartum completed suicides should be thoroughly investigated to guide prevention efforts.

The prevalence and correlates of self-harm ideation trajectories in Australian women from pregnancy to 4-years postpartum

OBJECTIVES

Women in the perinatal period are at increased risk of experiencing self-harm ideation. The current study longitudinally examines the prevalence, trajectories, and correlates of self-harm ideation in a population-based sample of Australian women from pregnancy through to the early years of parenting.

METHODS

Drawing on data from 1507 women participating in a prospective pregnancy cohort study, data were collected during pregnancy, at 3-, 6-, 12-, and 18-months postpartum, and 4-years postpartum. Longitudinal Latent Class Analysis was conducted to identify groups of women based on their responses to thoughts of self-harm at each time-point. Logistic regression analysis was used to identify factors associated with group membership.

RESULTS

Approximately 4-5% of women reported experiencing self-harm ideation at each time-point from pregnancy to 4-years postpartum. Cross-sectional analyses revealed that self-harm ideation was most frequently endorsed in the first 12-months postpartum (4.6%), and approximately 15% of women reported self-harm ideation at least once during the study period. Longitudinally, approximately 7% of women had an enduring pattern of self-harm ideation from pregnancy to 4-years postpartum. Women who had experienced a range of preconception and current social health issues and disadvantage were at increased risk of self-harm ideation over time.

LIMITATIONS

Limitations included use of brief measures, along with an underrepresentation of participants with particular socio-demographic characteristics.

CONCLUSIONS

A proportion of women are at increased risk of experiencing self-harm ideation during the perinatal period and in the early years of parenting, underscoring the need for early identification during pregnancy and early postpartum to facilitate timely early intervention.

Maternal depression and suicide at immediate prenatal and early postpartum periods and psychosocial risk factors

Maternal depression has been intensively explored; however, less attention has been paid to maternal suicide. No studies to date have observed maternal depression and suicide at immediate prenatal and early postpartum stages. In total, 213 Chinese women were recruited in hospitals after they were admitted for childbirth. All completed a short-term longitudinal survey at perinatal stages. Women reported lower depression scores (6.65) and higher suicidal ideation incidence (11.74%) after childbirth. Prenatal depression raised the possibility of prenatal suicidal ideation, while prenatal depression and suicidal ideation increased postpartum depression and suicidal ideation. At immediate prenatal stage, marital satisfaction protected women from depression, while miscarriage experiences and self-esteem increased the risk. At early postpartum stage, in contrast, being first-time mother, marital satisfaction, and harmony with mother-in-law prevented them from depression. Our study is among the first to confirm that women have decreased depression but increased suicidal ideation at early postpartum, and a causal relationship between them, which are worthy of public attention. Potential protective (marital satisfaction, being first-time mother, and harmony with mother-in-law) or risk factors (miscarriage experiences and self-esteem) of maternal depression and suicidal ideation are identified at perinatal stages. This offers reliable guidance for clinical practice of health care.

Low serum levels of High-Density Lipoprotein cholesterol (HDL-c) as an indicator for the development of severe postpartum depressive symptoms

Postpartum depression (PPD) is a psychiatric complication of childbirth affecting 10-20% of new mothers and has negative impact on both mother and infant. Serum lipid levels have been related to depressive disorders, but very limited literatures are available regarding the lipid levels in women with postpartum depression. The present study is aimed to examine the association of serum lipids with the development of postpartum depressive symptoms. This is a cross sectional study conducted at a tertiary care hospital in South India. Women who came for postpartum check-up at 6th week post-delivery were screened for PPD (September 2014-October 2015). Women with depressive symptoms were assessed using EPDS (Edinburgh Postnatal Depression Scale). The study involved 186 cases and 250 controls matched for age and BMI. Serum levels of lipid parameters were estimated through spectrophotometry and the atherogenic indices were calculated in all the subjects. Low serum levels of Total Cholesterol (TC) and High Density Lipoprotein cholesterol (HDL-c) were significantly low in PPD women with severe depressive symptoms. The study recorded a significant negative correlation between HDL-c and the EPDS score in PPD women (r = -0.140, p = 0.05). Interestingly, the study also observed a significant negative correlation between Body Mass Index (BMI) and EPDS scores in case group (r = -0.146, p = 0.047), whereas a positive correlation between the same in controls (r = 0.187, p = 0.004). Our study demonstrated that low levels of serum HDL-c is correlated with the development of severe depressive symptoms in postpartum women. Study highlights the role of lipids in the development of postpartum depressive symptoms.