Perinatal antidepressant use: understanding women's preferences and concerns

Maternal mental health as a major contributor to maternal mortality

Perinatal mental health conditions affect up to 20 % of pregnant or postpartum individuals, and nearly 15 % of pregnant individuals meet criteria for substance use disorder (SUD). All providers taking care of pregnant or postpartum individuals will encounter patients in these scenarios. Maternal Mortality Review Committees (MMRCs) have determined maternal mental health conditions, including SUD, to be the leading cause of preventable maternal death during pregnancy or in the first year postpartum. Lessons learned from MMRCs to prevent these deaths include the recommendation that screening and identification of mental health conditions need to be linked with evidence-based, patient-centered, and accessible treatments. Obstetricians and gynecologists, midwives, family medicine providers, and pediatricians, are in unique positions not only to screen and diagnose, but also to treat individuals with mental health concerns, including SUD, during pregnancy and postpartum.

Effectiveness of the mom supports mom peer support intervention in treating antenatal mental health difficulties in women

PROBLEM

Up to 75 % of at-risk perinatal women do not receive treatment in Czechia.

BACKGROUND

Pregnant women with mental health difficulties are more likely to undergo less controversial nonpharmaceutical treatment during pregnancy, but structural and psychological barriers interfere with their capacity to seek professional help.

AIM

We tested the effectiveness of the telephone-based peer support intervention Mom Supports Mom (MSM) in Czech pregnant women at risk of mental disorder.

METHODS

The Edinburgh Postnatal Depression Scale (EPDS) was used to assess risk in women (EPDS ≥ 10). Women at risk were randomized into two groups; the intervention group received the MSM, while the control group received the care as usual, which did not contain any psychological support intervention. One month after completing the EPDS, the women's mental statuses were again measured and compared, this time with data before and after the intervention, using the Perinatal Anxiety Screening Scale (PASS) to measure anxiety, the EPDS to measure depression, the Prenatal Psychosocial Profile (PPP) to measure stress, and the Prenatal Attachment Inventory - Revised (PAI-R) to measure attachment. The trial was registered under the name Pregnancy without psychosocial stress (ClinicalTrials.gov ID NCT04853693).

FINDINGS

A total of 167 women were included in the study and randomized into two groups. Depressive symptoms did not decrease (Cohen´s d; 95 % CI = 0.48; 0.17-0.79; p = .002), but levels of anxiety (Cohen´s d; 95 % CI = 0.44; 0.13-0.75; p = .005) and psychosocial stress (Cohen´s d; 95 % CI = 0.55; 0.20-0.82; p = .002) were reduced in women in the intervention group compared with women in the control. In addition, prenatal attachment increased among intervened women (Cohen´s d; 95 % CI = 0.48; 0.17-0.79; p = .002).

DISCUSSION

The telephone-based peer support intervention MSM is effective in reducing stress and anxiety and increasing prenatal attachment but does not reduce depression among high-risk women.

Partner support for women's antidepressant treatment and its association with depressive symptoms in pregnant women, mothers, and women planning pregnancy

PURPOSE

To examine the association between partner support for women's antidepressant treatment and depressive symptoms in pregnant women, those planning pregnancy, and mothers who ever used antidepressants.

METHODS

We included 334 women (n=44 planners, n=182 pregnant, n=108 mothers) ever treated with antidepressants within the HEALTHx2 study, a web-based cross-sectional study conducted across Norway in June 2020 to June 2021. The Edinburgh Postnatal Depression Scale and two questions of the Patient Health Questionnaire measured depressive symptoms, by degree of severity and for depressed mood, anxiety, and anhedonia sub-dimensions. Partner support was measured using one item from the Antidepressant Compliance Questionnaire. Association was estimated via unadjusted and adjusted linear and logistic regression models.

RESULTS

Being unsupported by the partner was associated with increased odds of reporting moderate-to-very-severe depressive symptoms in mothers (adjusted odds ratio (aOR), 3.57; 95% confidence interval (CI), 1.04-12.19) and pregnant women (aOR, 3.26; 95% CI, 0.95-11.14), relative to being supported. Pregnant women (adjusted mean difference (β), 0.76; 95% CI, 0.14-1.38) and mothers (β, 0.93; 95% CI, 0.23-1.64) with no support for their antidepressant treatment presented greater symptoms of anhedonia; for women planning pregnancy, this association emerged in relation to anxiety symptoms (β among non-users of antidepressant, 2.58; 95% CI, 1.04-4.13).

CONCLUSIONS

Partner support for women's antidepressant treatment may play a key role in depressive symptoms severity and the subtypes of anhedonia and anxiety, among women planning pregnancy, pregnant women, and mothers. This highlights the importance of partner inclusion in the complex decision-making process for antidepressant treatment around the time of pregnancy.

Identifying and synthesizing components of perinatal mental health peer support - a systematic review

Background

Becoming a parent, while often perceived as a joyous event, can also be a vulnerable life transition, with approximately one in five mothers experiencing perinatal mental illness. Peer support is recommended for its preventive and therapeutic benefits. However, relevant program components of perinatal mental health peer support remain to be identified.

Objectives

This review aims to (1) identify peer support programs in perinatal mental health through existing reviews and to (2) synthesize the components of these programs.

Methods

A systematic literature review guided by PRISMA was conducted searching four databases, supplemented by hand searches. The Template for Intervention Description and Replication (TIDieR) checklist facilitated the systematic extraction and synthesis of program components.

Results

Eleven peer support programs were identified from three reviews, largely conducted in English-speaking countries. The identified reviews highlight the benefits of peer support in perinatal mental health. Key components of individual programs were contextual background, materials, provider training and support, delivery modes and locations, and evaluation. Sharing lived experience and providing flexible support were central to all programs.

Conclusion

Aspects of flexibility, authenticity and the challenges of program evaluation in peer support must be considered. Findings can now inform future planning and implementation efforts of peer support programs in periantal mental health.

Comparative impact of exercise-based interventions for postpartum depression: A Bayesian network meta-analysis

OBJECTIVE

The current study aimed to address and rank which exercise-based interventions are preferable to standard care/no therapy or another exercise intervention for postpartum depression (PPD) management and provide estimates for future definitive evidence.

METHODS

The authors systematically searched PubMed, Embase, the Web of Science, PsycInfo, and ClinicalTrails.gov for randomized controlled trials (RCTs) on exercise-based interventions for PPD from their inception to May 9, 2023. Included were RCTs of exercise-based interventions for PPD with at least 4 weeks' duration. The pooled effects of intervention comparisons were generated by the Bayesian random-effects model, and the quality of evidence was evaluated by the Grading of Recommendations, Assessment, Development, and Evaluations framework.

RESULTS

Twelve RCTs (1260 women; mean age, 20-35 years) comparing exercise-based interventions with usual care/no therapy were included. Exercise effectively treats depressive symptoms (standard mean difference [SMD], -0.81 [95% confidence interval (CI), -1.20 to -0.42], P < 0.001). Pram walking was significantly associated with a reduction of depressive symptoms during the postpartum period (SMD, -1.00 [95% CI, -2.60 to -0.10], P = 0.020), as well as yoga (SMD, -0.73 [95% CI, -1.84 to -0.43], P < 0.001) and supervised mixed exercise (SMD, -0.77 [95% CI, -1.67 to -0.01], P = 0.041) compared with usual care/no therapy. In indirect comparisons, pram walking (surface under the cumulative ranking curve, 58.9%) was better than yoga (SMD, -0.28 [95% CI, -1.86 to 1.22], P = 0.322) and supervised mixed exercise (SMD, -0.23 [95% CI, -1.59 to 1.12], P = 0.358). However, the difference was not statistically significant. The confidence in evidence was very low to moderate.

CONCLUSION

In women with PPD, all commonly prescribed physical exercises were effective alternative or complementary treatments. However, pram walking may perform better in improving the symptoms of PPD.

Impact of perinatal exposure counseling on patient reported emotional outcomes and decisional empowerment

BACKGROUND

Exposures during pregnancy are common and most pregnant patients utilize at least one medication during pregnancy. The lack of reliable information on medication safety during pregnancy available to providers and patients is a stressor and obstacle to decision-making about medication use in pregnancy. Previous studies showed that exposures in pregnancy are associated with guilt, worry, and decisional conflict. Although prior research has evaluated changes in patient knowledge after teratogen counseling, studies have not examined emotional outcomes or patients' decisional empowerment. This quasi-experimental study measured changes in patients' feelings of guilt, anxiety, and decisional empowerment after receiving exposure counseling from trained teratogen information specialists.

METHODS

We administered pre- and post-counseling surveys to patients referred to a perinatal exposure clinic in Tampa, Florida. Validated scales were used to measure anxiety and guilt, and the 'SURE' measure was used to assess decisional empowerment. Paired samples t-tests evaluated changes in anxiety and guilt and a McNemar test assessed for changes in empowered decision making.

RESULTS

Among the 34 participants who completed both surveys, anxiety, and guilt scores decreased significantly (p < .001). While only 21% felt informed and empowered to make a decision related to their exposure(s) before counseling, this increased to 85% (p < .001) on the post-survey.

CONCLUSION

Comprehensive counseling with a trained teratogen information specialist improves patient emotional outcomes as well as feelings of empowerment to make an informed decision regarding medication use in pregnancy. This study highlights that patient-centered teratogen counseling goes beyond simple changes in patient knowledge.

Effect of antenatal micronutrient or antidepressant exposure on Brazelton neonatal behavioral assessment scale (NBAS) performance within one-month of birth

BACKGROUND

Antenatal depression is a risk factor for poor infant outcomes. Broad-spectrum-micronutrients (vitamins and minerals) have shown efficacy in treating psychiatric symptoms in non-pregnant populations and are associated with reduced incidence of adverse birth outcomes, and improvements in neonatal development. We investigated the effects of treatment of antenatal depression with micronutrients above the Recommended Dietary Allowance on infant development compared to treatment with antidepressant medications and controls.

METHOD

One-hundred-and-three infants were assessed using the Brazelton Neonatal Behavioral Assessment Scale (NBAS) within 28 days of birth: 37 exposed to micronutrients in-utero (50-182 days exposure), 18 to antidepressants in-utero (exposure for full gestation), and 48 controls whose mothers received neither treatment nor experienced depressive symptoms.

RESULTS

Controlling for gestational age and parity, there were significant group differences on habituation, orientation, motor, state regulation, autonomic stability and reflexes (p < .05). Micronutrient-exposed performed better than antidepressant-exposed and controls on habituation, motor and autonomic stability (p < .05), effect sizes ranged 1.0-1.7 and 0.5-1.0, respectively. Antidepressant-exposed performed significantly worse on orientation and reflexes compared to micronutrient-exposed and controls. Micronutrient-exposed had significantly better state regulation compared to antidepressant-exposed. There was an association between micronutrient exposure length and better habituation (r = 0.41, p = .028). Micronutrient exposure was generally identified as a stronger predictor of neonatal performance over maternal depression, social adversity, gestational age and infant sex.

CONCLUSION

In-utero micronutrient exposure appears to mitigate risks of depression on infant outcomes showing positive effects on infant behavior, on par with or better than typical pregnancies and superior to antidepressants. Limitations include differential exposure to micronutrients/antidepressants and lack of group blinding.

Screening, Assessment, and Treatment of Perinatal Mental Health in Obstetrical Settings

Perinatal mood and anxiety disorders (PMADs) are common, yet obstetricians receive little training prior to independent practice on screening, assessing, diagnosing, and treating patients with depression and anxiety. Untreated PMADs lead to adverse pregnancy and fetal outcomes. Obstetricians are in a unique position to address PMADs. The following serves as a resource for addressing PMADs in obstetric practice.

Management of Pregnant Women with Mental Disorders Requires Attention to Gestational Diabetes Mellitus

Background

Psychiatric interventions may be required during pregnancy. In the aspect of the management of psychiatric symptoms and the consideration of the need for pharmacotherapy, possibly to manage the effects on the fetus, pregnant women with mental disorders are considered high risk as other physical illnesses.

Objective

We investigated the characteristics of pregnant women with psychiatric disorders compared with high-risk pregnant women with physical illnesses at our university hospital and the effects of psychotropic drug use on pregnant women with mental disorders and their children.

Materials and Methods

In a multivariate analysis of 1282 pregnant women, excluding those with multiple pregnancies who gave birth at our hospital between January 2017 and the end of December 2019, we evaluated the effects of mental disorders and the use of psychotropic drugs throughout at least the third trimester up to the day of delivery on obstetric complications and infants. All data were collected retrospectively.

Results

Ninety-nine pregnant women had mental disorders and 62 took psychotropic drugs. Among multiple factors, pregnant women with mental disorders were associated with significantly higher rates of smoking and gestational diabetes mellitus (GDM) and significantly lower child abnormalities. The cause or effect was difficult to determine; however, the use of antipsychotics or antidepressants was also significantly associated with GDM, while psychotropic use was not related to any of the other factors investigated in this study.

Conclusions

Attention to GDM might be important in the management of pregnant women with mental disorders.

Testing a Behavioral Activation Gaming App for Depression During Pregnancy: Multimethod Pilot Study

BACKGROUND

Depression during pregnancy is increasingly recognized as a worldwide public health problem. If untreated, there can be detrimental outcomes for the mother and child. Anxiety is also often comorbid with depression. Although effective treatments exist, most women do not receive treatment. Technology is a mechanism to increase access to and engagement in mental health services.

OBJECTIVE

The Guardians is a mobile app, grounded in behavioral activation principles, which seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to assess app satisfaction and engagement and to explore changes in clinical symptoms of depression and anxiety among a sample of pregnant women with elevated depressive symptoms.

METHODS

This multimethod pilot test consisted of a single-arm, proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a pregnant sample with depression (N=18). Participation included two web-based study visits: (1) a baseline assessment to collect demographic and obstetric information and to assess clinical symptoms and (2) an exit interview to administer follow-up measures and explore user experience. Participants completed biweekly questionnaires (ie, Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7) during the trial to assess depression and anxiety symptom severity. App satisfaction was measured using 2 self-report scales (ie, Mobile Application Rating Scale and Player Experience of Needs Satisfaction scale). Engagement with The Guardians was captured using game interaction metric data. We used backward-eliminated mixed effects longitudinal models to examine the effects of app engagement and satisfaction and length of time in the study on symptoms of depression and anxiety. Content analysis was conducted on qualitative data from exit interviews.

RESULTS

The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively. Mixed effects models found significant negative main effects of week in study (β=-.35; t61=-3.05; P=.003), number of activities completed (β=-.12; t61=-2.05; P=.04), days played (β=-.12; t58=-2.9; P=.005), and satisfaction, according to the Mobile Application Rating Scale (β=-3.05; t45=-2.19; P=.03) on depressive symptoms. We have reported about similar analyses for anxiety. There is preliminary evidence suggesting harder activities are associated with greater mood improvement than easier activities. Qualitative content analysis resulted in feedback falling under the following themes: activities, app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications.

CONCLUSIONS

Preliminary results from this multimethod study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double those of previous public mental health apps, and use of the app was associated with significant decrease in depressive symptom scores over the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression.

Diet and the gut microbiota-immune axis in the context of perinatal mental health: Protocol for a prospective cohort study

BACKGROUND

Physiological and psychosocial changes experienced by women during the perinatal period may put them at risk for postpartum mental health disturbances. Accumulating evidence suggests that dietary patterns may influence mental health through the modulation of the gut microbiota and its effects on host immune activity. Thus, targeting the gut microbiota via dietary intake could serve as both a preventative and therapeutic strategy in improving perinatal mental health.

OBJECTIVES

Here, we present a protocol for a prospective cohort study that primarily aims to determine if diet quality during pregnancy is protective against postpartum depression severity. Secondary objectives will examine if microbiota- and blood-based inflammatory markers may be associated with the relationship between prenatal diet quality and postpartum depression severity, as well as with associations between additional dietary and mental health outcomes.

METHODS AND ANALYSIS

Dietary patterns and mental health symptoms will be documented in 100 pregnant women at 4 time points during pregnancy and postpartum. Participants will also provide stool and blood samples at the same time points to determine microbiota composition and predicted function and inflammatory factors, respectively. Stool microbiota will be analyzed using 16S ribosomal RNA gene sequencing and bioinformatics tools (QIIME 2/PICRUSt2). Inflammatory factors will be determined using high-sensitivity antibody-based immunoassays. Statistical analyses will include linear mixed models and hierarchical linear mixed effect models.

ETHICS

The study was approved by the Research Ethics Boards of the Royal Ottawa Health Care Group (#2022002) and of the University of Ottawa (#H-06-22-8013). Informed consent will be obtained from all participants before their enrollment.

DISCUSSION

Findings from this study will help develop evidence-based dietary recommendations and potential interventions for women susceptible to or suffering from postpartum mental health issues that are accessible, noninvasive, and have potential to play a role in prevention and treatment.

Developing and evaluating an interprofessional shared decision-making care model for patients with perinatal depression in maternal care in urban China: a study protocol

BACKGROUND

The majority of patients with perinatal depression (PND) in China do not receive adequate treatment. As forming a therapeutic alliance with patients is crucial for depression treatment, shared decision-making (SDM) shows promise in promoting patients' uptake of evidence-based mental health services, but its impact on patient outcomes and implementation in real-world maternal care remain uncertain. Therefore, this study aims to develop and evaluate an interprofessional shared decision-making (IP-SDM) model for PND to enhance maternal mental health services.

METHODS

This study contains four research phases: feasibility testing (Phase 1), toolkit development (Phase 2), usability evaluation (Phase 3), and effectiveness evaluation (Phase 4). During the development stage, focus group interviews will be conducted with expectant and new mothers, as well as maternal care providers for feasibility testing. A toolkit, including a patient decision aid along with its user guide and training materials, will be developed based on the findings of Phase 1 and syntheses of up-to-date evidence and appraised by the Delphi method. Additionally, a cognitive task analysis will be used for assessing the usability of the toolkit. During the evaluation stage, a prospective randomized controlled trial embedded in a mixed methods design will be used to evaluate the effectiveness and cost-effectiveness of the IP-SDM care model. The study targets to recruit 410 expectant and new mothers who screen positive for depression. They will be randomly assigned to either an intervention group or a control group in a 1:1 ratio. Participants in the intervention group will receive decision aid, decision coaching, and clinical consultation, in addition to usual services, while the control group will receive usual services. The primary outcome is the quality of decision-making process, and the secondary outcomes include SDM, mental health service utilization and costs, depressive symptoms, and health-related quality of life. In-depth interviews will be used to explore the facilitating and hindering factors of SDM.

DISCUSSION

This study will develop an IP-SDM care model for PND that can be implemented in maternal care settings in China. This study will contribute to the understanding of how SDM impacts mental health outcomes and facilitate the integration of mental health services into maternal care.

TRIAL REGISTRATION

ChiCTR2300072559. Registered on 16 June 2023.

Maternal Depression and Antidepressant Use During Pregnancy and Associations with Depressive Symptoms and Suicidality in Adolescent Children

Purpose

Children of mothers with prenatal depression have elevated risk for depression later in life. Pregnant women are hesitant to use antidepressants due to fear of adverse fetal effects. To inform prevention, this study examined associations between maternal prenatal depression and antidepressant use, and adolescent depressive symptoms and suicidality.

Patients and Methods

Prospective data from 74,695 mother-adolescent dyads from the Kaiser Permanente Northern California integrated healthcare delivery system were used. Three prenatal exposure groups were examined: maternal depression and antidepressants (Med); depression and no antidepressants (No-Med); neither depression nor antidepressants (NDNM). Adolescent depressive symptoms (Patient Health Questionnaire-2 score ≥3) and suicidality were assessed for 12- to 18-year-olds. Associations were analyzed using mixed effects logistic regression, adjusted for confounders.

Results

Maternal prenatal depression was associated with higher odds of adolescent depressive symptoms (Med odds ratio [OR]: 1.50, 95% confidence interval [CI]: 1.23-1.84; No-Med OR: 1.59, CI: 1.34-1.88) and suicidality (Med OR: 2.36, CI: 1.67-3.34; No-Med OR: 1.54, CI: 1.10-2.14) compared to no prenatal depression (NDNM). Adolescents exposed to prenatal depression and antidepressants were not at greater odds of depressive symptoms (Med OR: 0.95, CI: 0.74-1.21) compared to those not exposed to antidepressants (No-Med). However, they showed non-significant but greater odds of suicidality (Med OR: 1.54, CI: 0.99-2.39).

Conclusion

Our findings suggest that maternal prenatal depression is associated with adolescent depressive symptoms and suicidality, and that exposure to antidepressants in utero does not increase risk of depressive symptoms, specifically. While not statistically significant, the increased odds of suicidality among adolescents exposed to antidepressants suggest a possible association; however, further investigation is needed. After replication, the findings of this study may inform shared clinical decision-making when considering options regarding antidepressant use for the treatment of maternal prenatal depression.

Treatment options and their uptake among women with symptoms of perinatal depression: exploratory study in Norway and Portugal

BACKGROUND

Perinatal depression is the most undertreated clinical condition during the perinatal period. Knowledge about women's decision-making in seeking and receiving treatment is scarce.

AIMS

To investigate and compare treatment option uptake in perinatal women with depressive symptoms in Portugal and Norway, and to identify sociodemographic and health-related factors associated with treatment uptake.

METHOD

Participants were women resident in Portugal or Norway (≥18 years) who were pregnant or had given birth in the past 12 months, who presented with active depressive symptoms (Edinburgh Postnatal Depression Scale score ≥10). In an electronic questionnaire, women reported treatment received and sociodemographic and health-related factors.

RESULTS

The sample included 416 women from Portugal and 169 from Norway, of which 79.8% and 53.9%, respectively, were not receiving any treatment. Most Portuguese women were receiving psychological treatment, either alone (45.2%) or combined with pharmacological treatment (21.4%). Most Norwegian participants were receiving only pharmacological (36.5%) or combined treatment (35.4%). Compared with the Portuguese sample, a higher proportion of Norwegian women started treatment before pregnancy (P < 0.001). In Portugal, lower depressive symptoms and self-reported psychopathology were significantly associated with higher likelihood of receiving treatment.

CONCLUSIONS

We found that, in both Norway and Portugal, a substantial number of perinatal women with depressive symptoms do not receive any treatment. Differences exist regarding the chosen treatment option and timing of treatment initiation in the two countries. Only mental health-related factors were associated with treatment uptake for perinatal depression in Portugal. Our results highlight the importance of implementing strategies aimed to improve help-seeking behaviours.

Effect of Remote Peer-Counsellor- delivered Behavioral Activation and Peer-support for Antenatal Depression on Gestational Age at Delivery: a single-blind, randomized control trial

BACKGROUND

Antenatal depression (AD) is the most common complication of pregnancy in developed countries and increases the risk of preterm birth (PTB). Many pregnant individuals with AD do not obtain treatment due in part to risks associated with antidepressant medications, the expense and wait times for psychological services, and perceived stigma. Accessible and timely treatment of antenatal depression is crucial to minimize foetal impacts and associated long-term child health outcomes. Previous studies show that behavioural activation and peer support are promising avenues of treatment for perinatal depression. Additionally, remote and paraprofessional counselling interventions show promise as more accessible, sustainable, and cost-effective treatment avenues than traditional psychological services. The primary aim of this trial is to test the effectiveness of a remote, behavioural activation and peer support intervention, administered by trained peer para-professionals, for increasing gestational age at delivery among those with antenatal depression. The secondary aims are to evaluate the effectiveness for treating AD prior to delivery, with persistence into the postpartum; improving anxiety symptoms; and improving parenting self-efficacy compared to controls.

METHODS

A two-arm, single-blinded, parallel groups randomized controlled trial (RCT) with repeated measures will be conducted. Participants scoring >10 on the Edinburgh Postnatal Depression Scale will be recruited from the larger P3 cohort and invited to enroll. Assessments will be conducted prior to 27 weeks' gestation at trial intake (T1), post-intervention, prior to delivery (T2), 5-6 months postpartum (T3), and 11-12 months postpartum (T4) and will include self-report questionnaires and linked medical records.

DISCUSSION

Our remote, peer paraprofessional-delivered behavioural activation plus peer support intervention has the potential to successfully reduce symptoms of AD, which may in turn decrease the risk of PTB and subsequent health impacts. The current trial builds on previous findings and uses a patient-oriented approach to address priorities for patient care and to provide a cost-effective, accessible, and evidence-based treatment to pregnant individuals with AD.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN51098220) ISRCTN51098220. Registered on April 7, 2022.

Maternal antenatal depression's effects on child developmental delays: Gestational age, postnatal depressive symptoms, and breastfeeding as mediators

BACKGROUND

Maternal antenatal depression experienced around conception or during pregnancy may adversely affect child development. This study explores three potential mechanisms of the effects of antenatal depression on children's developmental delays at 2-3 years: gestational age of the child, continued depressive symptoms postnatally, and interrupted breastfeeding practices.

METHODS

Mothers (N = 2888) of 3450 children, including 2303 singletons and 1147 multiples from the Upstate KIDS cohort provided data. Linked hospital discharge data was combined with mothers' reports to identify women with moderate to severe antenatal depression. Gestational age was extracted from birth certificates. Mothers completed a depression screener at 4 months postpartum, reported about their breastfeeding practices from 4 to 12 months postpartum, and completed a developmental delay screener when children were 24, 30, and 36 months.

RESULTS

In unadjusted path analysis models, mothers with antenatal depression had more postnatal depressive symptoms and breastfed fewer months, which translated into children being more likely to have developmental delays. Gestational age was not a mediator. Effects were similar across girls and boys and singletons and twins, and largely held when adjusting for covariates.

LIMITATIONS

Main limitations were the relatively advantaged sample and reliance on maternal report.

CONCLUSIONS

Maternal antenatal depression may impact child development through continued depressive symptoms in the postpartum period and through reduced breastfeeding duration suggesting additional targets for intervention.

Maternal Mental Health Care Matters: The Impact of Prenatal Depressive and Anxious Symptoms on Child Emotional and Behavioural Trajectories in the French EDEN Cohort

Few studies have investigated longitudinal trajectories of child socioemotional and behavioural development in relation to maternal prenatal mental health exposure or taken into consideration of the potential buffering effects of psychological intervention during pregnancy. Using data from 1135 mother-child dyads from the EDEN cohort from the general French population, Group-based trajectory modelling was used to model trajectories of behavioural and emotional characteristics measured at four timepoints via a parent-administered Strengths and Difficulties Questionnaire. Using propensity scores and inverse probability weighting to account for confounding factors, multinomial logistic regressions were used to quantify the associations with maternal symptoms of prenatal depression and anxiety. Stratified analyses were conducted by reporting psychologist and psychiatrist consultations during pregnancy. Compared to those without psychological problems, children of mothers with comorbid anxiety and depression retained a higher probability of following high and intermediate trajectories of emotional problems and a high trajectory of conduct problems throughout childhood. This increased risk was not present in the children of mothers who sought support through a prenatal psychologist or psychiatrist consultation. This article adds to a body of evidence underlining the importance of mental health care for expecting mothers.

Intersection of Sex and Depression: Pathogenesis, Presentation, and Treatments

Major Depressive Disorder (MDD) is a highly prevalent, debilitating disorder. According to the World Health Organization, approximately 5% of adults suffer from depression worldwide and more women than men are affected. Yet, we have a very limited understanding of the pathogenesis of the disease, how sex and genetics influence the pathophenotype of MDD, and how they contribute to the responses to pharmacological treatment. This chapter addresses key theories about the etiology of depression, the variations in epidemiology and presentation, and the treatment options with respect to sex and gender. Additionally, we discuss the emerging wave of treatment modalities, diagnosis, and research focusing on MDD.

The Art of Holding Perinatal Women in Distress

Therapies like cognitive behavioral therapy and interpersonal psychotherapy are regarded as highly effective treatments for perinatal mood and anxiety disorders. Therapists appreciate robust research supporting the efficacy of these evidenced-based treatments and the structure of the tools these therapies provide for effective intervention. Less has been written on supportive psychotherapeutic techniques and few of those writings provide instruction or tools for therapists who wish to strengthen their skills in this therapeutic approach. This article describes The Art of Holding Perinatal Women in Distress™, a model of perinatal treatment developed by Karen Kleiman, MSW, LCSW. Kleiman instructs therapists to incorporate six "Holding Points" into their approach to therapeutic assessment and intervention for the purpose of establishing a holding environment conducive to the release of authentic suffering. This article reviews the Holding Points and provides a case study that elucidates how the holding points function within the context of a therapy session.

Does lack of exposure to individual antidepressants at different points during pregnancy associate with reduced risk of adverse newborn outcomes?

BACKGROUND

The objective of this study was to determine if the lack of exposure to individual antidepressants at certain times in pregnancy improved maternal and infant outcomes.

METHODS

This was a retrospective cohort study of 2741 pregnant women prescribed antidepressant(s) before or during pregnancy. Data were obtained from electronic medical records. Analysis was limited to women prescribed one of five antidepressants (bupropion, citalopram, escitalopram, fluoxetine, sertraline). Period of exposure was determined using prescription order dates. Primary outcomes were neonatal intensive care unit (NICU) admission and adaptation syndrome in the newborn. Logistic regression, adjusted for maternal age, race, and insurance, compared consistent exposure throughout pregnancy versus (A) no exposure in the third trimester, (B) no exposure early in pregnancy, and (C) exposure in the midtrimester alone.

RESULTS

Compared to women prescribed an antidepressant continually throughout pregnancy, NICU admission was less likely for women lacking exposure in the third trimester if they had been taking bupropion (aOR 0.43, 95% CI 0.21-0.90) or escitalopram (aOR 0.49, 95% CI 0.28-0.85). Women previously taking escitalopram but lacking third trimester exposure also had lower odds of adaptation syndrome (aOR 0.19, 95% CI 0.07-0.48). No differences were found in other outcomes for women taking other antidepressants or for any outcomes for women who lacked early pregnancy drug exposure compared to exposure throughout pregnancy.

CONCLUSION

For the five antidepressants included in this study, lack of exposure early or late in pregnancy compared to consistent exposure throughout pregnancy generally did not change newborn outcomes. The exceptions were bupropion and escitalopram, where lack of exposure in the third trimester associated with lower rates of adaptation syndrome or NICU admission. These data may help pregnant women with depression in need of drug therapy to have informed discussions with providers about the potential risks and benefits to continuing or stopping drugs at different times during pregnancy.

Effect of transcutaneous auricular vagus nerve stimulation on major depressive disorder with peripartum onset: A multicenter, open-label, controlled proof-of-concept clinical trial (DELOS-1)

BACKGROUND

Postpartum depression has a high prevalence in the United States (~13 %) and often goes undertreated/untreated. We conducted a multicenter, open-label, proof-of-concept trial to assess the Nēsos wearable, non-invasive, transcutaneous auricular vagus nerve stimulation (taVNS) system for the treatment of major depressive disorder with peripartum onset (PPD).

METHODS

Women (n = 25), ages 18 to 45, within 9 months postpartum, and diagnosed with PPD were enrolled at 3 sites. The study included 6 weeks open-label therapy and 2 weeks observation. Efficacy outcomes included change from baseline (CFB) in Hamilton Rating Scale for Depression (HAMD17) total scores, HAM-D17 response and remission, and patient and clinician global impression of change (PGIC, CGIC) scores. Analysis included descriptive statistics and mixed-effects models for repeated measures.

RESULTS

The most common AEs (≥5 %) were discomfort (n = 5), headache (n = 3), and dizziness (n = 2); all resolved without intervention. No serious AEs or deaths occurred. Baseline mean HAM-D17 score was 18.4. Week 6 least squares (LS) mean CFB in HAM-D17 score was -9.7; 74 % achieved response and 61 % achieved remission. At week 6, at least some improvement was reported by 21 of 22 (95 %) clinicians on CGIC and 22 of 23 (96 %) participants on PGIC.

LIMITATIONS

This was a single-arm, open-label study, and enrollment was limited to participants with mild-to-moderate peripartum depression.

CONCLUSION

Results from this proof-of-concept study suggest that the Nēsos taVNS system is well tolerated and may be an effective non-invasive, non-pharmacological treatment for major depressive disorder with peripartum onset. Further evaluation in larger sham-controlled studies is needed.

CLINICALTRIALS

govNCT03972995.

Perceived risk of neurodevelopmental outcomes in offspring related to psychotropic and mental illness exposures in pregnancy and breastfeeding: a cross-sectional survey of women with past or current mental illness

OBJECTIVES

To investigate the perceived risk of psychotropic and mental illness exposures (1) during pregnancy or (2) while breastfeeding on offspring neurodevelopment, and factors associated with this perception in women with past/current mental illness.

DESIGN

Cross-sectional, web-based study.

SETTING

Nationwide in Norway, June 2020-June 2021.

PARTICIPANTS

Women aged 18-55 years who were pregnant, recent mothers or planning a pregnancy, and had been offered antidepressants in the last 5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Perceived risk of prenatal and breastmilk exposure to psychotropic medications and maternal mental illness on offspring neurodevelopmental outcomes.

RESULTS

We included 448 women: 234 pregnant, 146 mothers and 68 planning a pregnancy. On a 0-10 scale, women perceived antidepressants as least harmful both (1) in pregnancy (mean score 4.2, 95% CI 3.6 to 4.8) and (2) while breastfeeding (mean score 3.8, 95% CI 3.3 to 4.4), relative to antipsychotics, anxiety/sleeping medication or antiepileptics (mean score range: 6.3-6.5 during pregnancy, 5.5-6.2 while breastfeeding). Many participants were unfamiliar with psychotropics other than antidepressants. The perceived risk of mental illness exposure exceeded that of antidepressants (mean score range 5.6-5.9) in both exposure periods. Using general linear models, factors associated with greater antidepressant risk perception in both exposure periods included having lower education, non-Norwegian native language, and employment status (range mean score difference (β): 2.07-6.07). For pregnant women and mothers, there was an inverse association between perceived risk and the perceived antidepressant effectiveness in both exposure periods (range of β: -0.18 to -0.25).

CONCLUSIONS

In women with past/current mental illness, the perceived risk of antidepressant exposure on child neurodevelopment was lower than that for maternal mental illness. Other psychotropic medications were perceived as more harmful. As medication risk perception influences the decision-making regarding treatment of mental illness, pre- and pregnancy counselling should target women with characteristics associated with higher perceived risk.

Maternal mental health and substance use disorders in sudden unexpected death in infancy using routinely collected health data in New Zealand, 2000-2016

BACKGROUND

Mortality from sudden unexpected death in infancy (SUDI) has declined dramatically since the 'Back to Sleep' campaign. Deaths now are more prevalent in those with socioeconomic disadvantage. The investigation of SUDI frequently identifies parents that have mental health or drug, alcohol and addiction problems.

AIMS

To estimate the prevalence of maternal mental health and substance use disorders and assess the magnitude of their risk for SUDI.

METHODS

We conducted a population-based cohort study using data from the Integrated Data Infrastructure (IDI), a large research database containing linked data from a range of government agencies. The study population was all live births and their mothers in New Zealand from 2000 to 2016. The exposures of interest were maternal mental health problems and maternal substance use disorders in the year prior to the birth. The outcome was deaths from SUDI.

RESULTS

The total population was 1086 504 live births and of these 1078 811 (99.3%) were able to be linked to other data sets within the IDI. The prevalence of maternal mental health problems in the total population was 5.2% and substance use disorder was 0.7%. There were 42 deaths from SUDI (0.75/1000) that were exposed to maternal mental illness and 864 deaths (0.84/1000) that were not exposed (adjusted relative risk (aRR)=1.23, 95% CI 0.90 to 1.68). There were 21 deaths from SUDI (2.67/1000) that were exposed to maternal substance use disorders and 885 (0.83/1000) that were not exposed (aRR=1.82, 95% CI 1.17 to 2.83).

CONCLUSIONS

Maternal substance use disorders, but not maternal mental health problems, in the year prior to the child's birth was associated with an increased risk of SUDI. However, the numbers that are affected are small and the effect size moderate. This group of women should receive additional SUDI prevention services and Safe Sleep advice.

A Review of Treatments and Clinical Guidelines for Perinatal Depression

Perinatal depression occurs in approximately 1 in 7 women and is considered the most common complication of pregnancy and childbearing. Management of perinatal depression may include a combination of nonpharmacological and pharmacological therapies depending on the severity of symptoms, the stage of gestation, and maternal preference. Healthcare providers are recommended to review current guidelines and provide information to women during pregnancy and postpartum regarding the risks and benefits of nonpharmacological and pharmacological treatment options for perinatal depression. In addition, healthcare providers should consider common barriers to treatment including inadequate screening and social stigma. This article reviews common treatments of perinatal depression as well as the clinical guidelines provided by the American Association of Obstetricians and Gynecologists (ACOG), the American Psychiatric Association (APA), and the US Preventive Services Task Force (USPSTF). Discussion of nonpharmacological therapies includes cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Pharmacological treatments are reviewed by drug class and include selective serotonin reuptake inhibitors (SSRIs), serotonin/norepinephrine reuptake inhibitors (SNRIs), norepinephrine/dopamine reuptake inhibitors (NDRIs), and tricyclic antidepressants (TCAs). Adjunctive treatments of severe depression, including second-generation antipsychotics (SGAs), are also discussed.

Exercise and yoga during pregnancy and their impact on depression: a systematic literature review

It is well established that exercise can improve depressive symptoms in the general population; however, it is not clear if these benefits are also seen in pregnancy. This review aimed to synthesize the evidence that examines whether exercise during pregnancy impacts depressive and associated symptoms (e.g. anxiety) during the perinatal period. The review was conducted in accordance with PRISMA guidelines and reporting criteria; literature was searched using PubMed, Scopus and Web of Science database engines. Clinical trials published in English evaluating the effects of a defined exercise protocol during pregnancy on depressive and/or anxiety symptoms during the perinatal period were included. Studies without a control group were excluded. Risk of bias was conducted by Cochrane assessment to appraise the quality of the included studies. Twenty-seven articles, between 1994 and 2019, were included. Of these, only 5 specifically recruited women with depression (n = 334), which all assessed a yoga-based intervention; 4 of these studies showed a statistically significant improvement in depressive and/or anxiety symptoms in the intervention group compared to baseline; however, 2 of these studies also showed an improvement in the control group. The remaining 22 studies used various exercise interventions in pregnant women (n = 4808) with 20 studies reporting that exercise during pregnancy has the ability to improve depressive and/or anxiety measures in the perinatal period compared to either baseline or control. The evidence suggests that exercise of various types in pregnancy can reduce depressive and/or anxiety symptoms in the perinatal period in otherwise healthy women. Specifically in women with antenatal depression, the incorporation of yoga in pregnancy can improve depressive/anxiety symptoms in the perinatal period; however, this is based on a small number of studies, and it is not clear whether this is superior to non-exercise controls. Further studies are needed to determine the potential therapeutic effects of exercise of various types during pregnancy on symptoms of antenatal depression.

Antidepressant use During Pregnancy: Knowledge, Attitudes, and Decision-Making of Patients and Providers

INTRODUCTION

Despite the risks associated with untreated perinatal depression and anxiety, both patients and clinicians are less likely to follow evidence-based guidelines including the use of antidepressants during pregnancy. The aim of this integrative review was to describe the perspectives of both patients and prescribing health care providers regarding the use of antidepressants during pregnancy.

METHODS

We performed a literature search in PubMed, CINAHL, ProQuest Central, and PsychINFO. Inclusion criteria were English language, original peer-reviewed research published within the previous 10 years that described perspectives regarding the use of antidepressants of pregnant patients or prescribing providers during pregnancy. Studies were excluded if their focus was on screening practices, treatment guidelines, or evaluation of decision support tool; medication or treatment broadly; bipolar disorder or serious mental illness; or they did not provide patient or provider perspective. This review was limited to professionals with scopes of practice that include prescriptive authority (eg, physicians, advanced practices nurses, midwives). Included articles were critically appraised and read in an iterative process to extract methodological details and synthesize findings.

RESULTS

Nineteen studies met criteria for inclusion and varied by design, sample, and quality. Together, the reviewed articles suggest that patients and prescribing providers hold a range of beliefs regarding the safety of antidepressant during pregnancy. Patients and providers appear to value different sources of information and varied in awareness of the negative impacts of untreated depression and anxiety during pregnancy. Many patients report dissatisfaction with available information and distress throughout the decision-making experience. Notably, patients and providers had incongruent perceptions of the others' experience.

DISCUSSION

Inconsistencies between knowledge, attitudes, and decision-making highlight the need for improved dissemination of evidence-based treatments and support increased training for psychopharmacology during pregnancy. Efforts to reduce patient distress regarding their decisions, such as adequate time and information, are indicated.

Gender-Oriented Mental Health Prevention: A Reappraisal

Many studies have investigated the impact of gender on mental health, but only a few have addressed gender differences in mental health risk and prevention. We conducted a narrative review to assess the current state of knowledge on gender-specific mental health preventive interventions, along with an analysis of gender-based risk factors and available screening strategies. Out of 1598 articles screened using a comprehensive electronic search of the PubMed, Web-of-Science, Scopus, and Cochrane databases, 53 were included for review. Among risk factors for mental health problems, there are individual, familiar, social, and healthcare factors. Individual factors include childhood adversities, which show gender differences in distribution rates. However, current childhood abuse prevention programs are not gender-specific. Familiar factors for mental health problems include maternity issues and intimate partner violence, and for both, some gender-specific preventive interventions are available. Social risk factors for mental health problems are related to education, employment, discrimination, and relationships. They all display gender differences, but these differences are rarely taken into account in mental health prevention programs. Lastly, despite gender differences in mental health service use being widely known, mental health services appear to be slow in developing strategies that guarantee equal access to care for all individuals.

Effect of peer support intervention on perinatal depression: A meta-analysis

BACKGROUND

To assess the effect of peer support on preventing or treating perinatal depression.

METHODS

Eight databases (Wanfang, VIP, CNKI, CBM, Pubmed, Embase, PsycINFO, and Cochrane) were systematically searched for eligible randomized controlled trials from inception to July 2021. Two reviewers critically and independently assessed the risk of bias using Cochrane Collaboration criteria and extracted correlated data using the designed extraction form.

RESULTS

A total of 16 studies (including 3154 participants, peer support group: 1568, control group: 1586) were included in this meta-analysis. The intervention group (peer support) had significantly better effect on preventing or treating perinatal depression than the control group [SMD = -0.39, 95% CI (-0.54, -0.24), P < 0.00001, I² = 78%]. The results of subgroup analyses showed that peer support interventions provided in the perinatal period [SMD = -0.51, 95% CI (-0.93, -0.09), P = 0.02] or only in the postpartum period could improve the depression of mothers [SMD = -0.44, 95% CI (-0.62, -0.26), P < 0.00001]. Face-to-face interventions [SMD = -0.28, 95% CI (-0.40, -0.15), P < 0.0001] and telephone/internet-based interventions [SMD = -0.73, 95% CI (-0.95, -0.50), P < 0.00001] were both effective for perinatal depression. As for form of intervention, the combination of individual and group sessions had the best effect on improving perinatal depression [SMD = -0.63, 95% CI (-1.04, -0.23), P = 0.002]. Peer support with the frequency of at least once a week had a significant effect on perinatal depression [SMD = -0.88, 95% CI (-1.32, -0.44), P < 0.0001]. Interventions with a length of ≤3 months [SMD = -2.20, 95% CI (-3.35, -1.04), P = 0.0002] worked better than those lasting for 3-36 months [SMD = -1.64, 95% CI (-2.38, -0.90), P < 0.0001] in perinatal depression management. Peer support could improve perinatal depression both in low- and middle-income countries [SMD = -0.70, 95% CI (-0.95, -0.45), P < 0.00001] and high-income countries [SMD = -0.15, 95% CI (-0.28, -0.02), P = 0.03].

CONCLUSIONS

Providing peer support during the perinatal period or only postpartum period, using Internet or telephone approaches, a combination of group and individual, at least once a week can be regarded as an effective measure to manage perinatal depression.

Randomized trial examining the effect of exercise and wellness interventions on preventing postpartum depression and perceived stress

BACKGROUND

Approximately 13-19% of postpartum women experience postpartum depression and a majority report at least some stress during the postpartum phase. Traditional interventions such as psychotherapy and antidepressant medications are often not feasible or desirable. The purpose of this study was to examine two low cost, brief, accessible interventions designed to prevent postpartum depression and perceived stress among women at high risk.

METHODS

Participants (n = 450) who were on average four weeks postpartum, had a history of depression before pregnancy, and exercised less than 60 min per week were randomly assigned to one of the following three conditions: (1) 6-month telephone-based exercise intervention; (2) 6-month telephone-based wellness/support intervention (e.g., healthy eating, sleep, and perceived stress); or (3) usual care.

RESULTS

Overall, 2.4% of participants met criteria for depression at 6 months and 3.6% at 9 months with no differences between groups. At 6 months following randomization, median symptoms of depression were significantly lower among wellness participants compared to usual care participants (b = - 1.00, SE = 0.46, p = .03). Perceived stress at 6 months post-randomization was significantly lower among exercise vs. usual care participants (b = - 2.00, SE = .98, p = .04) and exercise vs. wellness participants (b = - 2.20, SE = 1.11, p = .04).

CONCLUSIONS

The wellness intervention was efficacious for preventing symptoms of depression; however, postpartum depression that met the diagnostic criteria was surprisingly low in all conditions among this at risk sample of postpartum women. Exercise interventions may have a protective effect on perceived stress among women at risk for postpartum depression. Practitioners should consider integrating exercise and wellness interventions into postpartum care.

TRIAL REGISTRATION

Clinical Trials Number: NCT01883479 (06/21/2013).

Advancing health through research: A scoping review of and model for adjunctive psychosocial interventions to improve outcomes for perinatal women with bipolar disorder

BACKGROUND

We aimed to identify randomized clinical trials (RCTs) which evaluated the efficacy of adjunctive psychosocial interventions to improve outcomes during the perinatal period for women with bipolar disorder (BD).

METHODS

We scanned the literature to identify RCTs evaluating the efficacy of adjunctive psychosocial therapies or interventions provided during the perinatal period to women with BD. We searched from 1946 to July 2020 using Embase, Ovid Medline, PsycINFO, and Scopus. We then searched for future, current, and recently completed RCTs described on www.ClinicalTrials.gov.

RESULTS

This scoping review (1946 - July 2020) revealed no published RCTs for this population. The findings expose an important gap in research and knowledge, as well as a health disparity.

CONCLUSION

We heuristically tied a mechanistic stress reduction model to relevant findings. The initial hypotheses are informed by effective stress reducing psychosocial interventions for: a) people with BD outside the perinatal period and b) perinatal women with major depressive disorder (MDD may improve the health of perinatal women with BD). We hypothesize that the perinatal trajectory of health for women with BD will improve by adding psychosocial interventions or therapies to treatment as usual. We propose maternal stress reduction as a potential mediator/mechanism.

LIMITATIONS

Findings reported are limited to the methods of a scoping review. Reproductive status tends to be a missing variable; we highlight the need for its inclusion. Interdisciplinary, collaborative research to improve the treatment outcome for perinatal women with BD is warranted and ripe for advancement.

The Before Baby Relationship Checkup: A Couples-Based Intervention to Reduce Relationship Risk Factors for Perinatal Mood and Anxiety Disorders

Relationship conflict and lack of partner support are risk factors for perinatal mood and anxiety disorders. An intervention to strengthen couples' relationships before birth may reduce relationship risk factors for perinatal mood and anxiety disorders, though no research has explored this to date. The aims of this Stage 1 open-series non-experimental proof of concept study were to adapt the 'Marriage Checkup', an evidence-based intervention for relationship distress, as a preventative intervention for perinatal mood and anxiety disorders and to assess its feasibility and acceptability. Pregnant women receiving care at a university-based obstetric practice, and their partners, were recruited. Ten couples participated in the Before Baby Relationship Checkup, a personalized relationship health service offered in the obstetric clinic. Quantitative and qualitative data gathered suggests the intervention is feasible to implement in an obstetric setting, and acceptable to perinatal couples. Specific adaptations to the Marriage Checkup for perinatal couples are warranted and further testing is needed to evaluate efficacy.

Patient-Centered Care for Patients with Depression or Anxiety Disorder: An Integrative Review

People have specific and unique individual and contextual characteristics, so healthcare should increasingly opt for person-centered care models. Thus, this review aimed to identify and synthesize the indicators for the care process of the person with depression and/or anxiety disorders, based on patient-centered care, going through the stages of diagnostic assessment and care planning, including intervention. An integrative literature review with research in seven scientific databases and a narrative analysis were carried out. Twenty articles were included, with indicators for diagnostic evaluation and care/intervention planning being extracted. Care planning focused on people with depression and/or anxiety disorder must be individualized, dynamic, flexible, andparticipatory. It must respond to the specific needs of the person, contemplating the identification of problems, the establishment of individual objectives, shared decision making, information and education, systematic feedback, and case management, and it should meet the patient's preferences and satisfaction with care and involve the family and therapeutic management in care. The existence of comorbidities reinforces the importance of flexible and individualized care planning in order to respond to the specific health conditions of each person.

Effectiveness of patient decision aids in women considering psychotropic medication use during pregnancy: a literature review

Women face complicated decisions regarding psychotropic medication use during pregnancy. Patient decision aids (PDAs) could be a valuable tool to assist with decision-making. The objective of this review was to evaluate the effectiveness of PDAs in this population. A systematic search of the literature was conducted using PRISMA guidelines. Three major databases were searched to identify articles published between 2006 and June 2020. Studies were included if they evaluated use of a PDA for women considering medication for mental illness during pregnancy. A total of 4629 titles were returned from the search; however, only three studies met inclusion criteria and were selected for analysis. Two were pilot randomised controlled trials in women considering antidepressant use during pregnancy, and one was a non-randomised study in women considering medication for the treatment of opioid use disorder (OUD). The PDAs had good acceptability across all three studies. The randomised trials assessed knowledge, decisional conflict, depression, and anxiety, with non-significant trends towards reduced decisional conflict and anxiety in the PDA groups. PDAs have the potential to assist women with mental illnesses to make decisions regarding medication use during pregnancy; however, current evidence is too limited to evaluate the effectiveness of PDAs for this population.

Effectiveness of psychological interventions in the treatment of perinatal depression: A systematic review of systematic reviews and meta-analyses

BACKGROUND

Perinatal depression is a high prevalent mental health problem with serious consequences. Evidence about effective psychological interventions in treating perinatal depression has been increasing, but it lacks a comprehensive synthesis of findings.

METHODS

A systematic review of systematic reviews and meta-analyses concerning the effectiveness of psychological interventions in treating perinatal depression (depression during pregnancy and the first 12 months postpartum) in adult women was conducted. The electronic databases MEDLINE (PubMed), PsycINFO, The Cochrane Library, Web of Science and Prospero were searched, on May 2020, using a combination of keywords. Data were independently extracted by two authors and a synthesis of the results was presented. Methodological quality was independently assessed by two authors, using AMSTAR-2.

RESULTS

Seven systematic reviews were included and reported, overall, the effectiveness of psychological interventions in decreasing depressive symptoms in women in the perinatal period, both short and long-term. CBT was found to be the most effective intervention, regardless of the treatment format.

LIMITATIONS

Grey literature was not searched, and some studies may overlap among the included systematic reviews. These (the included reviews) were rated with low methodological quality, which weakens the evidence of the reported results.

CONCLUSIONS

CBT is currently the most evidence-based psychological intervention, provided in different delivery formats (individual, group, face-to-face or Internet-based). Further studies, including systematic reviews, with other types of psychological interventions (e.g., third-wave CBT) and with higher quality are needed.

Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians' Training, Current Practices and Perceived Strategies to Improve Future Implementation

Background:

This study aimed to explore clinicians’ perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation.

Methods:

This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States.

Results:

Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services.

Conclusions:

Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.

Omega-3 polyunsaturated fatty acid (n-3 PUFA) supplementation for prevention and treatment of perinatal depression: a systematic review and meta-analysis of randomized-controlled trials

BACKGROUND

Available interventions for preventing and treating perinatal depression remain unsatisfactory.

AIMS

We examined the prophylactic and therapeutic effects, as well as adverse effects, of n-3 PUFA supplementation in reducing depressive symptoms during perinatal periods.

METHODS

We included randomized, placebo-controlled trials that reported the changes of depression severity after the perinatal participants received n-3 PUFA supplementation. After the comprehensive searches in October 2019, we selected the trials, extracted the data, and assessed the quality of included trials. We compared the standardized mean differences (SMD) of depression score changes between groups using a random-effect model.

RESULTS

We included 11 trials in the meta-analysis and one more trial for qualitative analysis (N = 3,181). The pooled standardized mean of decreased depression scores revealed no statistically significant difference between the n-3 PUFA and the placebo groups (N = 920, SMDs = -0.05, 95% CI -0.20 to 0.10, I² = 21%). The pooled SMDs showed no statistically significant efficacy of n-3 PUFA supplementation for prevention (N = 779, SMDs = -0.03, 95% CI -0.20 to 0.13, I² = 24%) and treatment (N = 141, SMDs = -0.14, 95% CI -0.55 to 0.27, I² = 31%) of perinatal depression. The efficacy of n-3 PUFA supplementation was not associated with the daily doses of DHA, EPA, or DHA plus EPA. No trial reported any serious adverse effect of n-3 PUFA supplements.

CONCLUSIONS

Although n-3 PUFA supplementation may improve maternal and infant outcomes, our meta-analysis found insufficient evidence to determine its benefit for perinatal depression.

Light therapy for mood disorders

In this chapter, light therapy for mood disorders is discussed, including mood disorders during and after pregnancy. In the introduction, we discuss the symptomatology, etiology, and treatment of a specific type of mood disorder, seasonal affective disorder, since it kick-started the first clinical trials with light therapy. Second, we elaborate on the pathophysiology of mood disorders, in particular in the peripartum period. Next, we present an overview of the proposed working mechanisms of light therapy, followed by a discussion of the clinical trials that have followed after the initial research in seasonal affective disorder. Finally, we also focus on the limitations of these trials, such as considerable heterogeneity among studies and many methodological shortcomings. This is complemented by a number of suggestions for future research. Further studies are needed, which stems from the fact that the results have not always been consistent. Despite this, light therapy may be a promising treatment option for various types of mood disorders, since it shows a significant reduction in symptoms in many patients with few adverse effects.

Perinatal Anxiety and Depression in Minority Women

Depression and anxiety are common during pregnancy and are experienced at higher rates among women who are racial and ethnic minorities. Because depression and anxiety influence maternal and infant outcomes, intervening to improve perinatal mental health should be a priority for all healthcare providers. However, in the United States, a number of barriers including lack of mental health providers, lack of perinatal behavioral health systems, and stigma, limit access to care. Universal screening has been recommended and here we examine how universal screening can help nurses improve the mental health of childbearing women. Interventions that are currently in use to improve perinatal anxiety and depression are reviewed and include: psychopharmacology, cognitive behavioral therapy, interpersonal psychotherapy, and mindfulness. Recommendations for future research and healthcare system changes are made.

Pregnancy and Delivery Outcomes Following Benzodiazepine Exposure: A Systematic Review and Meta-analysis

OBJECTIVE

Understanding the effects of benzodiazepines (BZDs) on maternal/fetal health remains incomplete despite their frequent use. This article quantifies the effects of antenatal BZD exposure on delivery outcomes.

DATA SOURCES

Medline, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched till June 30, 2018.

STUDY SELECTION

English-language cohort studies comparing antenatal BZD exposure to an unexposed group on any delivery outcome were eligible. In all, 23,909 records were screened, 56 studies were assessed, and 14 studies were included.

DATA EXTRACTION

Two reviewers independently assessed quality and extracted data. Estimates were pooled using random effects meta-analysis. Sub-analyses examined several potential moderators including timing of exposure.

RESULTS

There were 9 outcomes with sufficient data for meta-analysis. Antenatal BZD exposure was significantly associated with increased risk of 6 outcomes initially: spontaneous abortion (pooled odds ratio = 1.86; 95% confidence interval [CI], 1.43 to 2.42), preterm birth (1.96; 95% CI, 1.25 to 3.08), low birth weight (2.24; 95% CI, 1.41 to 3.88), low Apgar score (2.19; 95% CI, 1.94 to 2.47), Neonatal Intensive Care Unit (NICU) admission (2.61; 95% CI, 1.64 to 4.14), and induced abortion (2.04; 95% CI, 1.23 to 3.40). There was significant heterogeneity between studies for most outcomes without consistent moderators. Birth weight (mean difference [MD]: -151.35 g; 95% CI, -329.73 to 27.03), gestational age (-0.49 weeks; 95% CI, -1.18 to 0.19), and small for gestational age (SGA; 1.42; 95% CI, 1.00 to 2.01) did not show significant associations although after adjusting for publication bias, gestational age, and SGA became significant, totaling 8 significant outcomes.

CONCLUSIONS

Antenatal BZD exposure appears to be statistically associated with increased risk of several adverse perinatal outcomes. Although confounds cannot be ruled out, NICU admission does appear clinically relevant and consistent with the antidepressant literature.

Trends in mental health and substance use disorders and treatment receipt among pregnant and nonpregnant women in the United States, 2008-2014

PURPOSE

To compare trends in mental health and substance use disorders and treatment receipt of pregnant and nonpregnant women from 2008 to 2014.

METHODS

Using data from the 2008-2014 National Survey on Drug Use and Health, logistic regression was used to compare trends in mental health and substance use disorders and treatment receipt for mental health and substance use disorders among propensity score-matched groups of pregnant (n = 5520) and nonpregnant women (n = 11,040). Among women in the matched sample who met criteria for at least one mental illness, trends in mental health treatment receipt of pregnant (n = 1003) and nonpregnant women (n = 2634) were compared.

RESULTS

There were no differences in the trends by pregnancy status from 2008 to 2014. Past-year anxiety disorder, past-month psychological distress and illicit drug use disorder increased in the total sample from 2008 to 2014, yet trends in mental health treatment and unmet need for substance use treatment did not change over time. Pregnant women had lower odds of mental illness, but those who had mental illness were less likely to receive mental health treatment than their nonpregnant counterparts.

CONCLUSIONS

There is a need for preventive strategies addressing anxiety disorder, psychological distress and illicit drug use among women of childbearing age as well as initiatives to increase access to mental health treatment among pregnant women.