Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5

Pregnancy care experiences for adults with congenital heart disease in the United States

BACKGROUND

Research to reduce maternal morbidity due to cardiovascular disease is vitally important in the United States, especially for the growing number of individuals with congenital heart disease (CHD) reaching childbearing age. Understanding patient experiences through patient engagement is critical to designing research that is aligned with the needs of adults with CHD undergoing pregnancy.

METHODS

This patient engagement project, grounded in human centered design, focuses on the discovering patient and healthcare provider priorities for reducing maternal morbidity in CHD through patient centered outcomes research (PCOR). In this first stage, a capacity building consortium of over 90 key partners, including patients, advocates, healthcare providers, and researchers, was assembled. Baseline education on patient engagement, PCOR, and survey instrument design was delivered virtually. Two questionnaires were designed to elicit tacit knowledge - 1 for patients and 1 for providers - regarding gaps and needs across 4 key pillars: access to clinical care, patient and provider education, mental health, and research opportunities. The pillars were determined through thematic summaries from consortium discussions.

RESULTS

The patient questionnaire received 828 responses (age range: 18-60 years) from 48 U.S. states. The provider questionnaire garnered 218 responses from professionals. Several common themes for areas of research were observed across all pillars including improved access to specialized cardio-obstetric care and improved education about the need for specialized care. Healthcare providers cited insufficient care coordination models and resources as a major barrier to providing effective clinical care. Both patients and providers expressed a need for improved access to mental health care. While only 28% of patient respondents who underwent a pregnancy reported a pre-existing mental health diagnosis, nearly 2/3 reported having significant anxiety symptoms related to their pregnancy. Of those with significant symptoms, 44% were unable to access mental health services. Additionally, only 55% of healthcare providers reported referral for assessment and treatment if mental health concerns arose during or after pregnancy.

CONCLUSION

The results provide valuable insights into the unique challenges faced by patients with CHD and their providers during pregnancy. By addressing the identified gaps through PCOR, we can work towards a goal to improve maternal care for women with CHD.

Addressing Perinatal Mood and Anxiety disorders in Obstetric Settings: Results of a Cluster Randomized Controlled Trial of Two Approaches

BACKGROUND

Mood and anxiety disorders affect one in five perinatal individuals and are undertreated. While professional organizations and policy makers recommend that obstetric practices screen for, assess and treat mood and anxiety disorders, multi-level barriers to doing so exist. To help obstetric practices implement the recommended standard of care, we developed implementation assistance, an approach to guide practices on how to integrate screening, assessment, and treatment of mood and anxiety disorders into the obstetric practice workflow. To teach obstetric care clinicians how to treat perinatal mood and anxiety disorders, we also developed an e-learning course and toolkit.

OBJECTIVE(S)

Evaluate the extent to which 1) implementation assistance + e-learning/toolkit, and 2) e-learning/toolkit alone improved the rates and quality of care for perinatal mood and anxiety disorders in obstetric practices, as compared to usual care.

STUDY DESIGN

We conducted a cluster randomized controlled trial involving 13 obstetric practices across the United States (US). Using 2:2:1 randomization, 13 obstetric practices were assigned to 1) implementation assistance + e-learning/toolkit (n=5), 2) e-learning/toolkit alone (n=5), or 3) usual care (n=3). We measured obstetric care clinicians' quality of care for perinatal mood and anxiety disorders (as measured by medical record documentation of screening, assessment, treatment initiation, and monitoring) documented in patient charts (n=1,040). Effectiveness was assessed using multilevel generalized linear mixed models, accounting for clustering of repeated measurements (n=2, i.e., pre and post) within obstetric care clinicians' patient charts (n=40) nested within practices (n=13). Intention-to-treat and per-protocol analyses were conducted.

RESULTS

At baseline, no significant differences were observed among the three groups regarding documented mental health screening. Chart extraction at eight months post-training revealed a significant increase in recommended bipolar disorder screening only among the practices that received the implementation plus e-learning/toolkit (from 0.0% to 30.0%; p = 0.017). Practices receiving the e-learning/toolkit alone or usual care continued to not screen for bipolar disorder. Documented screening for anxiety also increased in the implementation + e-learning/toolkit group (from 0.5% to 40.2%), however, did not reach statistical significance when compared to the other groups (p = 0.09). A significant increase in documented post-traumatic stress disorder (PTSD) screening was observed among practices receiving the implementation plus e-learning/toolkit (0.0% to 30.0%; p = 0.018). The quality-of-care score in the implementation + e-learning toolkit group increased from 20.5 at baseline to 42.8 at follow-up and was significantly different from both the e-learning/toolkit alone group (p = 0.02) and the usual care group (p = 0.03). At eight months post-training, the implementation + e-learning/toolkit group had higher mean provider readiness scores than the other two groups for documentation of screening, assessment, and monitoring. However, documentation of treatment was the only component that reached statistical significance (p =0.025).

CONCLUSION(S)

Among the practices that followed the implementation protocols, implementation assistance + e-learning/toolkit was effective in improving rates of screening for bipolar disorder, anxiety, and PTSD. However, three of the five practices did not follow the implementation protocols, suggesting that the intensity of the implementation needs to be tailored based on practice readiness for implementation.

Antipsychotic use during pregnancy and outcomes in pregnant individuals and newborns

BACKGROUND

Despite the increasing use of antipsychotics during pregnancy, comprehensive evaluations of their individual safety profiles using global data remain limited. This study aimed to assess the safety of various antipsychotics during pregnancy by comparing them to quetiapine, which has a relatively large body of safety data.

METHOD

Utilizing the World Health Organization pharmacovigilance database (1967-2023; n = 131,255,418 reports), we identified 11,406 reports of antipsychotic exposure during pregnancy. A disproportionality analysis was performed to calculate reporting odds ratios (RORs) for adverse pregnancy, fetal, or neonatal outcomes associated with haloperidol, ziprasidone, clozapine, olanzapine, risperidone, aripiprazole, and paliperidone, compared to quetiapine.

RESULTS

Haloperidol had a significantly higher reporting frequency for congenital malformations compared to quetiapine (ROR 3.83; 95 % CI, 2.62-5.59). No statistically significant differences were found for other antipsychotics regarding congenital malformations or neonatal complications compared to quetiapine. All studied antipsychotics had lower reporting frequencies for gestational diabetes mellitus than quetiapine (overall ROR 0.22; 95 % CI, 0.18-0.28). Haloperidol, clozapine, olanzapine, risperidone, and aripiprazole were more frequently reported for abortion or stillbirth. Paliperidone and ziprasidone demonstrated similar or lower frequencies of major adverse outcomes compared to quetiapine, suggesting comparable safety during pregnancy.

LIMITATIONS

Incomplete data and reporting bias hinder establishing causality.

CONCLUSIONS

Compared to quetiapine, several antipsychotics with less established safety data, particularly ziprasidone and paliperidone, may be safely used during pregnancy. However, further research is needed to verify these findings and ensure the safety of these antipsychotics as treatment options during pregnancy.

Predictors of Inflammation-Mediated Preterm Birth

Preterm birth remains a worldwide health concern because of ongoing challenges in prediction and prevention. Current predictors are limited by poor performance, need for invasive sampling, and an inability to identify patients in a timely fashion to allow for effective intervention. The multiple etiologies of preterm birth often have an inflammatory component. Thus, a deeper understanding of the inflammatory mechanisms involved in preterm birth may provide opportunities to identify new predictors of preterm birth. This review discusses the multiple etiologies of preterm birth, their links to inflammation, current predictors available, and new directions for the field.

Lithium Use During Pregnancy in 14 Countries

Importance

In pregnancy, the benefits of lithium treatment for relapse prevention in psychiatric conditions must be weighed against potential teratogenic effects. Currently, there is a paucity of information on how and when lithium is used by pregnant women.

Objective

To examine lithium use in the perinatal period.

Design, Setting, and Participants

This cohort study used individual-level data of pregnancies from January 1, 2000, to December 31, 2021, in Australia, Denmark, Finland, Germany, Hong Kong, Iceland, Israel, New Zealand, Norway, South Korea, Sweden, Taiwan, the UK, and 2 cohorts in the US. Analyses were performed from September 1 to November 30, 2023.

Exposures

The prevalence of lithium use as the proportion of pregnancies with at least 1 prescription fill or prescription within 3 months before pregnancy until childbirth was estimated using a common protocol. Lithium use during pregnancy by trimester and in the 3 months before and after pregnancy was examined.

Main Outcomes and Measures

Comparison of prevalence between the first and last 3-year periods of available data.

Results

Among 21 659 454 pregnancies from all collaborating sites, the prevalence of lithium use ranged from 0.07 per 1000 pregnancies in Hong Kong to 1.56 per 1000 in the US publicly insured population. Lithium use increased per 1000 pregnancies in 10 populations (Australia [0.60 to 0.74], Denmark [0.09 to 0.51], Finland [0.10 to 0.29], Iceland [0.24 to 0.99], Israel [0.25 to 0.37], Norway [0.24 to 0.47], South Korea [0.30 to 0.44], Sweden [0.42 to 1.07], the UK [0.07 to 0.10], and Taiwan [0.15 to 0.19]), remained stable in 4 populations (Germany [0.17 to 0.16], Hong Kong [0.06 to 0.06], and the publicly [1.50 to 1.34] and commercially [0.38 to 0.36] insured US populations), and decreased in 1 population (New Zealand [0.54 to 0.39]). Use of lithium decreased with each trimester of pregnancy, while prevalence of postpartum use was similar to prepregnancy levels. The proportion of lithium use in the second trimester compared with the prepregnancy period ranged from 2% in South Korea to 80% in Denmark.

Conclusions and Relevance

Prevalence of lithium use in pregnant women over the past 2 decades varied markedly between populations. Patterns of use before, during, and after pregnancy suggest that many women discontinued lithium use during pregnancy and reinitiated treatment after childbirth, with large variations between countries. These findings underscore the need for internationally harmonized guidelines, specifically for psychiatric conditions among pregnant women that may benefit from lithium treatment.

Associations between maternal depression trajectories and infant neurodevelopment at eight months

BACKGROUND

Maternal depression is an increasingly recognized risk factor of child neurodevelopment difficulties. Few studies have investigated the association between the severity and duration of maternal depression and child development. We aimed to identify whether trajectories of maternal depressive symptoms from pregnancy to six months postpartum are associated with child development at eight months.

METHODS

We included 988 mother-child pairs who participated in Shenzhen Birth Cohort Study, which was conducted in Shenzhen Nanshan Maternity & Child Healthcare Hospital of China. Maternal depressive symptoms were evaluated by the Edinburgh Postnatal Depression Scale (EPDS) at late pregnancy, 1, 3 and 6 months postpartum. Child emotional and behavioral development were assessed by Ages and Stages Questionnaires: Social-Emotional (ASQ-se) and Ages and Stages Questionnaires-Third Edition (ASQ-3) at aged 8 months. Latent profile analysis (LPA) was used to identify the trajectories of maternal depressive symptoms. Univariate and multivariate linear regression were conducted to explore the association between the depressive symptoms trajectories and child development.

RESULTS

Four trajectories of maternal depressive symptoms were identified by LPA: low (n = 597), subclinical (n = 91), moderately low and increasing (n = 246) and persistently high (54). Multivariable regression model showed that children of mothers with persistently high depressive symptoms were more likely to have lower scores in three ASQ-3 domains: fine motor (beta [95%C]): -2.30 [-4.32, -0.29], problem-solving (-3.72 [-5.81, -1.62]) and personal-social motor (-2.56 [-4.98, -0.15]), but higher ASQ-se scores (9.49 [5.09, 13.9]). Compared to children of mothers with low depressive symptoms, subclinical depressive symptoms were prediposed to having lower scores in two ASQ-3 domains: communication motor (-2.48 [-4.32, -0.64]) and gross motor (-2.35 [-4.2,-0.51]) and lower ASQ-se scores(4.86 [2.54, 7.18]).

CONCLUSION

Higher levels of maternal depression symptoms were associated with increased risk of child developmental delay, highlighting the importance of early intervention and addressing maternal depression from pregnancy through early childhood.

Mood stabilizers for treatment of bipolar disorder in pregnancy and impact on neonatal outcomes

INTRODUCTION

Untreated bipolar disorder in pregnancy is associated with adverse maternal and neonatal outcomes. Despite advances in clinical management, there is concern among obstetric providers and patients about the safety of pharmacological agents for the treatment of bipolar disorder in pregnancy. Recent studies have shown atypical antipsychotics and lamotrigine to have a favorable safety profile; however, little information is published on lurasidone.

OBJECTIVES

The objective of this retrospective chart review was to evaluate pregnancy and neonatal outcomes in obstetric patients with bipolar disorder who are untreated, compared to those treated with lurasidone, other atypical antipsychotics, and lamotrigine at a tertiary teaching institution.

METHODS

This retrospective cohort study included neonates whose mothers had a diagnosis of bipolar disorder and were referred to the Maternal & Fetal Care Clinic with two documented visits after January 1, 2014, with delivery by October 31, 2017, within an SSM health-system hospital.

RESULTS

In this study, women with untreated bipolar disorder (not on any mood stabilizer) in pregnancy had significantly higher rates of premature delivery and low birth weight compared to women on mood stabilizers of lamotrigine, lurasidone, and other atypical antipsychotics. No difference was observed for pregnancy or neonatal outcomes between patients taking any of the mood stabilizers.

CONCLUSIONS

This study suggests that the use of lurasidone, other atypical antipsychotics, and lamotrigine have better neonatal outcomes than untreated bipolar disorder in pregnancy.

The Association of Antidepressants in Late Pregnancy with Postpartum Hemorrhage: Systematic Review of Controlled Observational Studies

Introduction: Despite advances in obstetric care, postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. Prior reviews of studies published through 2016 suggest an association of antidepressant use during late pregnancy and increased risk of PPH. However, a causal link between prenatal antidepressants and PPH remains controversial. Objectives: This systematic literature review aimed to synthesize the empirical evidence on the association of antidepressant exposure in late pregnancy with the risk of PPH, including studies published before and after 2016. Methods: A systematic literature search was conducted using PubMed, OVID Medline, EMBASE, SCOPUS, PsycINFO, and CINAHL from inception to September 9, 2023. Original, peer-reviewed studies (published in English) that reported on the frequency or risk of PPH in women with evidence of antidepressant use during pregnancy and included at least one control group were included. Results: Twenty studies (eight published after 2016) met inclusion criteria, most of which focused on the risks of PPH associated with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). The main findings from the individual studies were mixed, but the majority documented statistically significant associations of PPH with late prenatal exposure, especially for exposures occurring within 30 days of delivery, compared with unexposed deliveries. Fourteen studies addressed underlying antidepressant indications or their correlates. Few studies focused on prenatal antidepressants and the risk of well-defined severe PPH or on antidepressant dose changes and general PPH risk. None examined competing risks of antidepressant discontinuation on mental health outcomes. Conclusions: Late pregnancy exposure to antidepressants may be a minor risk factor for PPH, but it is unclear to what extent reported associations are causal in nature, as opposed to correlational (effects related to nonpharmacological factors including maternal indication). For patients needing antidepressants during pregnancy, current evidence does not favor routinely discontinuing antidepressants specifically to reduce the risk of PPH.

Synopsis of the 2023 U.S. Department of VA and U.S. DoD Clinical Practice Guideline for the Management of Pregnancy

INTRODUCTION

This Clinical Practical Guideline provides recommendations based on a systematic review of the evidence to address critical decision points in the management of pregnancy. The guideline is intended to improve patient outcomes and local management of patients who are pregnant. This CPG is based on a systematic review of both clinical and epidemiological evidence and was developed by a panel of multidisciplinary experts. The Work Group provides clear and comprehensive evidence-based recommendations incorporating current information and practices targeting practitioners throughout the DoD and VA Health Care systems. The guideline is intended to improve patient outcomes and local management of patients who are pregnant. This CPG does not address every aspect of routine pregnancy care and is not intended to be a comprehensive guide to all care needed in pregnancy. It also addresses some clinically important and generally accepted standards of pregnancy care interventions that do not have sufficient high-quality evidence to support standalone recommendations. Additionally, it highlights emerging topics that have the potential to impact pregnancy care in the future and identifies gaps in the literature that warrant further research.

MATERIALS AND METHODS

The development of all VA/DoD guidelines is directed by the Evidence-Based Practice Guideline Work Group and adheres to the standards for trustworthy guidelines that were set by the National Academy of Medicine. A patient focus group was convened to assess important aspects of treatment for patients and to gain information about patient values and preferences. The Lewin Group, a contracted third party with expertise in CPG development, facilitated meetings and the development of key questions using the population, intervention, comparison, outcome, timing, and setting format. Consensus was achieved among the Work Group through an iterative process involving discussions on conference calls and in person during the recommendation development meeting. An independent third party, ECRI, conducted the systematic evidence review, which the guideline Work Group then used to develop recommendations using the Grading of Recommendations Assessment, Development and Evaluation system (7-9). The search methods and results are detailed in the full guideline.

RESULTS

This CPG provides 28 clinical practice recommendations that cover selected topics that the Work Group deemed had high priority need for evidence-based standards. The recommendations are divided into 3 main categories: routine care, complicated obstetrics, and mental health. An algorithm delineating recommended interventions and appropriate timing of these interventions over the course of the pregnancy and postpartum period was also created.

CONCLUSION

The CPG is not intended to define standards of care nor address all care needed in pregnancy; it does provide comprehensive guidance for routine pregnancy care. It aligns with the VA and DOD's goal of providing care that is consistent in quality and utilization of resources in efforts to reduce errors and inappropriate variations in practices. In total, the Work Group identified 71 items needing further study, including areas requiring stronger evidence to support current recommendations and newer topics that will guide future guideline development.

Prolonged transcranial magnetic stimulation in a pregnant patient with treatment-resistant depression: a case report

INTRODUCTION

Perinatal depression is a serious and highly prevalent medical condition in the USA. Nearly 85% of individuals with perinatal depression go untreated, leading to significant morbidity and mortality. There is an urgent need to develop and advance safe and effective treatments for perinatal depression. Transcranial magnetic stimulation is an established intervention for depression in non-pregnant individuals yet is not well studied in perinatal depression.

CASE PRESENTATION

A 33-year-old pregnant Latina female presented with severe, recurrent, treatment-resistant depression and suicidal ideation. The patient had previously trialed psychotherapy, multiple antidepressants, and mood stabilizers and had achieved remission with lithium prior to pregnancy. Due to pregnancy and fetal safety concerns, the patient discontinued lithium and consequently suffered progressive worsening of perinatal depression. At 24 weeks gestation and after additional failed medication trials, a prolonged course of transcranial magnetic stimulation was initiated. Following 46 transcranial magnetic stimulation treatments over 9 weeks using two protocol types (repetitive transcranial magnetic stimulation and intermittent theta burst stimulation), she achieved near-remission of perinatal depression and resolution of suicidal ideation. There were no identified maternal or fetal adverse events at 6 weeks post-delivery.

CONCLUSION

To our knowledge, this is the first published case of a pregnant individual with perinatal depression who received and tolerated a prolonged transcranial magnetic stimulation course with two distinct protocols (repetitive transcranial magnetic stimulation and intermittent theta burst stimulation) with clinically significant response. Transcranial magnetic stimulation is a well-tolerated and effective intervention that warrants further investigation for use in treatment-resistant perinatal depression.

Zuranolone for the Treatment of Postpartum Depression

Objective

To review the safety, efficacy, and tolerability of zuranolone for the treatment of postpartum depression.

Data Sources

A literature search was conducted through PubMed using the following terms: zuranolone, postpartum depression, perinatal depression, SAGE-217, and allopregnanolone analogue.

Study Selection and Data Extraction

Articles describing the pharmacology, pharmacokinetics, efficacy, safety, and/or tolerability of zuranolone were included in this review.

Data Synthesis

Zuranolone is an allopregnanolone analogue that works through modulation of the GABAA receptor. Clinical trials have demonstrated that compared with placebo, zuranolone is effective in treating patients with postpartum depression. Common adverse events associated with zuranolone include fatigue, somnolence, headache, dizziness, diarrhea, sedation, upper respiratory tract infection, and nausea.

Conclusions

Pharmacotherapeutic options to treat postpartum depression include selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, with the medication brexanolone (the first allopregnanolone analogue) reserved for severe postpartum depression. Zuranolone, the newest medication in its class, is without the same limitations as brexanolone, thus affording providers an additional easy-to-use option for treating postpartum depression.

New treatments: Opportunities and challenges

Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each patient. Furthermore, provider, local, and systemic factors complicate access to current treatment options. New and emerging approaches offer the potential of more effective treatment for specific perinatal psychiatric disorders. From neuroactive steroid medications to accelerated psychotherapy interventions, recent innovations have demonstrated enhanced efficacy on a faster timeline. Optimally, these developments will also lower barriers to care but this is not necessarily true. We review novel and upcoming interventions across perinatal mental illness and place them in the context of existing treatments and common challenges.

Models of care: Opportunities and challenges

Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.

Call For Action: The Obstetrician's Role In Peripartum Mental Health

Peripartum mental health is an underdiagnosed and undertreated entity; obstetricians are in a dilemma when patients present with signs of any mental disturbance. The peripartum period is fraught with triggers that can cause, or exacerbate, mental illness, and obstetricians need to be aware of diagnoses and treatment of blues, depression, psychosis and other problems. Key strategies that can be adopted are discussed in this review, along with the scenario in India.

An Integrated Approach to Address Perinatal Mental Health Within an Obstetrics Practice

Outpatient perinatal care providers (one certified nurse-midwife, one nurse practitioner, and one physician assistant) at a high-volume, suburban health system in southeastern Pennsylvania developed and implemented a care model to identify and care for patients at risk for perinatal and postpartum mental health conditions. The program, Women Adjusting to Various Emotional States (WAVES), was created to bring the most up-to-date, evidence-based treatment recommendations to patients while addressing the increased demand placed on the health care system by pregnant and postpartum patients in need of psychiatric services. WAVES is a specialized program offered for anyone who is pregnant or up to one year postpartum who is struggling with mental health symptoms or concerns. Perinatal mood and anxiety disorders have become one of the most prevalent pregnancy ailments, yet mental health is not always addressed during routine prenatal care visits. Common obstacles to patients obtaining mental health care during pregnancy include lack of access, clinician gaps in knowledge, and stigma surrounding diagnoses. WAVES offers a method to empower perinatal providers with the education and tools to address this need. The model outlines how to appropriately assess, diagnose, manage, or refer patients for mental health services. Patient feedback has been overwhelmingly positive, and this novel care model shows great promise for the future of perinatal care. The development of integrated programs like WAVES may be a valuable resource to help combat the perinatal mental health epidemic.

Treating obesity and fertility in the era of glucagon-like peptide 1 receptor agonists

The objective of this narrative review is to advocate for improved comprehensive care of patients with obesity and infertility. Persons with an increased body mass index have less successful reproductive outcomes, and recently, new medications to treat neuroendocrine hormone imbalances are producing meaningful weight loss akin to surgical interventions. For the first time, obesity is publicly being recognized as a disease. These medications contain the newest generation of glucagon-like peptide 1 receptor agonists and deserve our attention for several reasons: regardless of body mass index, many patients will be using them; it is necessary to understand the mode of action, side effects, and implications for anesthetic procedures and pregnancy; and it is important to evaluate when they could be used to improve health outcomes and/or access to fertility care.

Behavioral Health Trends Among Perinatal North Carolina Medicaid Beneficiaries

Untreated behavioral health conditions among the perinatal population are associated with high mortality and morbidity. We examined trends of behavioral health conditions and treatment received by perinatal Medicaid beneficiaries and described the characteristics of providers treat-ing these beneficiaries from 2017 to 2022. Results indicated that 24.4% of beneficiaries had a behav-ioral health diagnosis, 13.8% received a psycho-tropic prescription, and 7.1% received a behavioral health service.

Alleviating anxiety while breastfeeding: evaluating buspirone transfer into human milk

PURPOSE

Buspirone, an anxiolytic with minimal risk of dependence or respiratory depression, lacks extensive published data on its transfer into human milk during lactation. The objective of this study was to 1) quantify the transfer of buspirone and its active metabolite 1-pyrimidinylpiperazine (1-PP) into human milk, allowing for an estimation of maternal drug exposure to the breastfed infant, and 2) report observations of the infants exposed to buspirone via breastmilk.

METHODS

Milk samples and health histories were collected from nine lactating mothers who donated milk samples to the InfantRisk Human Milk Biorepository while taking buspirone. The drug concentration-time profile of buspirone and 1-PP was determined using liquid chromatography-mass spectrometry.

RESULTS

Buspirone was below the detection level of 1.5 ng/mL in all milk samples with dosages ranging from 7.5 to 30 mg twice daily. However, low levels of active metabolite 1-PP were observed at 7.5 mg twice daily up to 30 mg twice daily. The relative infant dose (RID) calculated ranged from 0.21 to 2.17%, which is below the standard 10% threshold for infant safety. There were no reports of adverse effects in the exposed infants.

CONCLUSION

The levels of buspirone observed in all participants' milk samples were exceedingly low. The subsequently low relative infant dose (RID) in the range of 0.21% to 2.17% is below the 10% threshold for infant safety, suggesting that the transfer of maternal buspirone and its active metabolite (1-PP) into human milk is clinically insignificant and poses minimal risk to a breastfed infant.

Causal associations between vitamin D and postpartum depression: A bidirectional mendelian randomization study

Background

Previous epidemiological studies have reported associations between vitamin D and postpartum depression (PPD); however, the findings are inconsistent. This study employs bidirectional Mendelian Randomization (MR) to investigate the causal link between serum 25-hydroxyvitamin D [25(OH)D] levels and PPD. By utilizing genetic data from cohorts, this research aims to provide a more robust understanding of the potential relationship between vitamin D and PPD, addressing a critical gap in the current literature.

Methods

A bidirectional MR analysis was conducted to investigate the genetic association between serum 25(OH)D and PPD using summary statistics extracted from GWAS datasets. The study included data from 15,668 patients with PPD and 376,755 healthy controls of European ancestry. The GWAS data for 25(OH)D were obtained from two studies within the UK Biobank, encompassing 496,946 and 79,366 participants. The primary analysis employed the inverse-variance weighted (IVW) method, while supplementary MR estimates were derived through the MR-Egger and weighted median (WME) methods. Furthermore, sensitivity analyses were implemented to ensure robustness and reliability, including Cochran's Q test, MR-PRESSO, MR-Egger intercept test, and the leave-one-out test.

Results

The MR study revealed no substantial genetic correlation between serum 25(OH)D levels and PPD (OR = 1.065, 95%CI = 0.878-1.293, P = 0.522 for set A; OR = 0.978, 95 % CI = 0.669-1.430, P = 0.910 for set B). Additionally, in the reverse analysis, we did not observe a significant causal impact of PPD on serum 25(OH)D (OR = 1.001, 95%CI = 0.974-1.028, P = 0.951 for set A; OR = 1.011, 95%CI = 0.992-1.031, P = 0.261 for set B). The results obtained from MR-Egger and WME analyses concord with those derived from the IVW method. Conducting leave-one-out tests did not identify any single nucleotide polymorphism that might have influenced the MR results, confirming the robustness and reliability of the findings.

Conclusions

The results suggest the absence of a causal link between vitamin D concentrations and PPD. Inconsistent observations in previous observational studies may be attributed to residual confounding.

Zuranolone Concentrations in the Breast Milk of Healthy, Lactating Individuals: Results From a Phase 1 Open-Label Study

PURPOSE/BACKGROUND

Zuranolone is a positive allosteric modulator of both synaptic and extrasynaptic γ-aminobutyric acid type A receptors and a neuroactive steroid approved as an oral, once-daily, 14-day treatment course for adults with postpartum depression in the United States. This study assessed zuranolone transfer into breast milk.

METHODS/PROCEDURES

Healthy, nonpregnant, lactating adult female participants received once-daily 30 mg zuranolone from day (D)1 through D5 in this phase 1 open-label study. The relative infant dose (RID; weight-adjusted proportion of the maternal dose in breast milk over 24 hours) for 30 mg zuranolone was assessed at D5. An RID for 50 mg zuranolone was estimated using a simulation approach across a range of infant ages and weights.

FINDINGS/RESULTS

Of 15 enrolled participants (mean age, 30.1 years), 14 completed the study. The mean RID for 30 mg zuranolone at D5 was 0.357%; the mean steady-state milk volume over D3 to D5 decreased from baseline by 8.3%. Overall unbound zuranolone in plasma was low (≤0.49%). Plasma concentrations peaked at D5 before decreasing in a biexponential manner. There was strong concordance between the temporal profiles of zuranolone concentrations in plasma and breast milk. The estimated mean RID for 50 mg zuranolone based on a milk intake of 200 mL/kg per day was 0.984%. All treatment-emergent adverse events reported by participants were mild, the most common being dizziness (n = 3).

IMPLICATIONS/CONCLUSIONS

Zuranolone transfer into the breast milk of healthy, nonpregnant, lactating adult female participants was low; the estimated RID for 50 mg zuranolone was <1%, well below the <10% threshold generally considered compatible with breastfeeding.

Gaps between current practice in perinatal depression screening and guideline recommendations: a systematic review

OBJECTIVE

Screening for perinatal depression is recommended by many guidelines to reduce the disease burden, but current implementation practices require clarification.

METHOD

Fifteen databases were searched for observational studies using a pre-tested search strategy. In addition, the websites of academic organizations were searched for guidelines, recommendations, and reports. Literature published between January 1, 2010, and December 19, 2021, in either English or Chinese, was included. The standard form of the Joanna Briggs Institute (JBI) was used to assess risk of bias of the included studies.

RESULTS

The data analysis covered 103 studies, 21 guidelines, 11 recommendations, five position statements, three reports, two committee opinions, three consensuses, one consultation, and one policy statement. All but one guideline recommended that mothers be routinely screened for perinatal depression at least once during the perinatal period. In addition, 39 documents recommended that perinatal mothers at risk of perinatal depression be provided with or referred to counseling services. In original studies, however, only 8.7% of the original studies conducted routine screenings, and only one-third offered referral services after the screening process. The EPDS emerged as the most frequently used screening tool to measure perinatal depression. 32% (n = 33) of studies reported the technology used for screening. The most commonly used method was face-to-face interviews (n = 22). Screening personnel the agents conducting the screening comprised researchers (n = 26), nurses (n = 15), doctors (n = 11).

CONCLUSIONS

A significant disparity was observed between the recommendations and implementation of perinatal depression screening, highlighting the need to integrate routine screening and referral processes into maternal care services.

Prescription psychostimulant use, admissions and treatment initiation and retention in pregnant people with opioid use disorder

While attention deficit hyperactivity disorder is common among people with addiction, the risks and benefits of attention deficit hyperactivity disorder medication in pregnant people with opioid use disorder are poorly understood. Here, using US multistate administrative data, we examined 3,247 pregnant people initiating opioid use disorder treatment, of whom 5% received psychostimulants. Compared to peers not receiving psychostimulants, the psychostimulant cohort had greater buprenorphine (adjusted relative risk 1.81 (1.50-2.18)) but lower methadone initiation (adjusted relative risk 0.39 (0.19-0.78)). Among psychostimulant recipients who initiated buprenorphine, we observed lower buprenorphine discontinuation associated with the psychostimulant cohort compared to nonrecipients (adjusted hazard ratio 0.77 (0.67-0.88)). In within-person case-crossover analyses, person-days defined by psychostimulant fills were associated with fewer substance use disorder-related admissions compared to days without fills (odds ratio 0.50 (0.33-0.76)). Overall, our data suggest that psychostimulant use in pregnancy may be associated with increased buprenorphine initiation, decreased methadone initiation and improved buprenorphine retention. Decreased substance use disorder-related admissions were associated with person-days of psychostimulant receipt, although other risks of psychostimulant use in pregnancy warrant further investigation.

Zuranolone: The First FDA-Approved Oral Treatment Option for Postpartum Depression

OBJECTIVE

The objective of this study was to review the characteristics, efficacy, and safety of zuranolone in the management of postpartum depression (PPD).

DATA SOURCES

Literature was identified using PubMed (1966-August 2023) and EMBASE (1973-August 2023) and clinicaltrials.gov. Search terms included zuranolone, SAGE-217, and PPD with further limitation of those published in English.

STUDY SELECTION AND DATA EXTRACTION

Articles selected for inclusion included trials evaluating zuranolone for the treatment of PPD.

DATA SYNTHESIS

Zuranolone was evaluated for the treatment of moderate to severe PPD in 2 phase III trials. Both studies resulted in statistically significant improvement in depressive symptoms at day 15 (P = 0.003 and P < 0.001). Sustained differences in remission rates favoring zuranolone were found in both studies at day 45 compared with placebo (P = 0.01 and P < 0.05). Zuranolone was well tolerated, with somnolence, dizziness, headache, and sedation reported as the most common side effects.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS

Zuranolone is only the second medication approved by the Food and Drug Administration (FDA) for PPD and offers an advantage over brexanolone in that it can administered orally in the outpatient setting. The rapid onset of effect of zuranolone is advantageous to traditional antidepressant therapy which can be weeks to months; however, limited information is available on safety during lactation.

CONCLUSIONS

The recent FDA approval of oral zuranolone for PPD offers a second rapid-acting treatment for PPD, extending the opportunity for treatment to patients in the outpatient setting.

NICU Parent and Staff Advocacy to Address Parental Mental Health

Parents of infants requiring neonatal intensive care unit (NICU) hospitalization often experience increased rates of distress, trauma, and perinatal mood disorders. Untreated parental mental health conditions have short- and long-term effects for infants and families. While some NICUs provide varying degrees of mental health supports for NICU families, these services are not universally or systematically integrated in US NICUs. Multiple factors contribute to this gap in care, including mental health stigma, funding constraints, and lack of staff training and capacity. In an effort to address this gap, we used a participatory action research approach, guided by a Patient and Stakeholder Engagement model, to partner with graduate NICU parents and patient-facing NICU staff to identify parental mental health needs and ideas to address them. Through efforts to mitigate power differentials and engage parents as research and program development partners, our work shaped NICU practices, programming, and subsequent research.

Discrimination and perinatal depressive symptoms: The protective role of social support and resilience

BACKGROUND

Discrimination is an important social determinant of perinatal depression; however, evidence is limited regarding modifiable social and psychological factors that may moderate this association. We examined whether social support and resilience could protect against the adverse effects of discrimination on perinatal depressive symptoms.

METHODS

Pregnant people (N = 589) receiving Expect With Me group prenatal care in Nashville, TN and Detroit, MI completed surveys during third trimester of pregnancy and six months postpartum. Linear regression models tested the association between discrimination and depressive symptoms, and the moderating effects of social support and resilience, during pregnancy and postpartum.

RESULTS

The sample was predominantly Black (60.6 %), Hispanic (15.8 %) and publicly insured (71 %). In multivariable analyses, discrimination was positively associated with depressive symptoms during pregnancy (B = 4.44, SE = 0.37, p ≤0.001) and postpartum (B = 3.78, SE = 0.36, p < 0.001). Higher social support and resilience were associated with less depressive symptoms during pregnancy (B = -0.49, SE = 0.08, p < 0.001 and B = -0.67, SE = 0.10, p < 0.001, respectively) and postpartum (B = -0.32, SE = 0.07, p < 0.001 and B = -0.56, SE = 0.08, p < 0.001, respectively). Social support was protective against discrimination (pregnancy interaction B = -0.23, SE = 0.09, p = 0.011; postpartum interaction B = -0.35, SE = 0.07, p < 0.001). There was no interaction between discrimination and resilience at either time.

LIMITATIONS

The study relied on self-reported measures and only included pregnant people who received group prenatal care in two urban regions, limiting generalizability.

CONCLUSIONS

Social support and resilience may protect against perinatal depressive symptoms. Social support may also buffer the adverse effects of discrimination on perinatal depressive symptoms, particularly during the postpartum period.

Psychiatric emergencies during pregnancy and puerperium in low - And middle-income countries

Pregnancy and puerperium are critical points in women's health, and various psychiatric emergencies may worsen or manifest (for the first time) during this period. In the presence of a psychiatric emergency, the pregnancy and puerperium outcomes may be compromised. In addition to the mother being at risk, the health of the fetus and the newborn may also be compromised if the psychiatric emergency is not managed appropriately. Early detection and collaborative approaches between mental health practitioners and obstetricians are of utmost importance in women who are at risk and those living with psychiatric illnesses during pregnancy and puerperium. Practitioners should also ensure that women with impaired capacity due to psychiatric disease are treated in a non-judgmental and respectful manner, even if their autonomies have been overridden.

Barriers to help-seeking for postpartum depression mapped onto the socio-ecological model and recommendations to address barriers

Postpartum depression affects nearly a quarter of women up to a year after childbirth. Although it is treatable, significant barriers to help-seeking prevent women from being treated. This paper assesses key literature on the barriers for help-seeking among women with postpartum depression. The barriers identified have been mapped onto the socio-ecological model in addition to potential recommendations that professionals can use to address barriers on individual, interpersonal, organizational, community and societal levels. The recommendations provided are meant to serve as leverage points for professionals in efforts to create appropriate support and interventions. As such, this paper serves as a mapping tool for healthcare and public health professionals to assess obstacles to women's help-seeking and to guide multi-pronged interventions on various levels of the socio-ecological model that may increase help-seeking among women with postpartum depression. Holistically and comprehensively providing support to women will require significant effort throughout all sectors of society as opposed to isolated, siloed interventions.

Assessment of Postpartum Stress Using the Maternal Postpartum Stress Scale (MPSS) in Spanish Women

Although scales that evaluate postpartum stress exist, they lack specificity in maternal postpartum stress. The MPSS was created because there was a need to assess maternal stress during the postpartum stage. The introduction of the MPSS has enriched the evaluation tools for postpartum stress and has helped understand maternal stress at various postpartum time points and identify women at high risk for postpartum stress during this period. The aim was to translate the MPSS into Spanish and study its psychometric properties. Postpartum women (N = 167) with a mean age of 34.26 (SD = 4.71) were involved in this study. In addition to the MPSS, a battery of instruments was administered: a demographic sheet, the Birth Satisfaction Scale-Revised (BSS-R) and the Edinburgh Postnatal Depression Scale (EPDS). The MPSS data were analyzed, checking item communality first. As a result, three items showed unsatisfactory communality values (h2 < 0.40). Confirmatory Factor Analysis was conducted, comparing factor models using the full pool of MPSS items or the version without items with unacceptable communality. As a result, the original three-factor structure was endorsed on the Spanish MPSS, with better fit indices when removing items with low communality (RMSEA = 0.067, CFI = 0.99, TLI = 0.99). The reliability of this version was satisfactory (ω = 0.93). Finally, group comparisons for some perinatal variables were performed, showing no significant differences between groups of interest (p = 0.05 and above). To conclude, the MPSS will contribute to the existing literature, having a wider capacity to assess perinatal mental health difficulties in Spanish-speaking populations.

Zuranolone: A Narrative Review of a New Oral Treatment for Postpartum Depression

PURPOSE

Postpartum depression is a prevalent and overlooked mental disorder. Pathophysiology is thought to originate from a combination of biological and social factors, including hormones, and genetics. The consequences of untreated postpartum depression can be severe and negatively impact maternal and infant health. Zuranolone was approved as an oral agent in August 2023 for the treatment of postpartum depression in adults. The purpose of this article is evaluating the clinical aspects of zuranolone, including safety and efficacy pertaining to the drug and the clinical data that led to its approval.

METHODS

A literature search was conducted using PubMed, Web of Science, and EMBASE with the terms postpartum depression, postpartum depression management, and zuranolone to locate relevant data for this narrative review. The prescribing information of zuranolone and clinicaltrials.gov were also utilized.

FINDINGS

Two Phase III trials (Study 1-NCT04442503 and Study 2-NCT02978326) led to the approval of zuranolone by the Food and Drug Administration (FDA) based on clinically meaningful improvement in depressive symptoms. The trials met their primary endpoint, a change from baseline in HAM-D total score at day 15 (Study 1; 95% CI -6.3 to -1.7, P = 0.001: Study 2; 95% CI (-6.9 to -1.5, P = 0.003).

IMPLICATIONS

Zuranolone, an oral and rapidly acting antidepressant, represents a promising new oral treatment option for individuals with postpartum depression.

Environmental enrichment attenuates depressive-like behavior in maternal rats by inhibiting neuroinflammation and apoptosis and promoting neuroplasticity

Gestational stress can exacerbate postpartum depression (PPD), for which treatment options remain limited. Environmental enrichment (EE) may be a therapeutic intervention for neuropsychiatric disorders, including depression, but the specific mechanisms by which EE might impact PPD remain unknown. Here we examined the behavioral, molecular, and cellular impact of EE in a stable PPD model in rats developed through maternal separation (MS). Maternal rats subjected to MS developed depression-like behavior and cognitive dysfunction together with evidence of significant neuroinflammation including microglia activation, neuronal apoptosis, and impaired synaptic plasticity. Expanding the duration of EE to throughout pregnancy and lactation, we observed an EE-associated reversal of MS-induced depressive phenotypes, inhibition of neuroinflammation and neuronal apoptosis, and improvement in synaptic plasticity in maternal rats. Thus, EE effectively alleviates neuroinflammation, neuronal apoptosis, damage to synaptic plasticity, and consequent depression-like behavior in mother rats experiencing MS-induced PPD, paving the way for new preventive and therapeutic strategies for PPD.

Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression

INTRODUCTION

Our consensus statement aims to clarify the use of antidepressants and anxiolytics during breastfeeding amidst clinical uncertainty. Despite recent studies, potential harm to breastfed newborns from these medications remains a concern, leading to abrupt discontinuation of necessary treatments or exclusive formula feeding, depriving newborns of benefits from mother's milk.

METHODS

A panel of 16 experts, representing eight scientific societies with a keen interest in postpartum depression, was convened. Utilizing the Nominal Group Technique and following a comprehensive literature review, a consensus statement on the pharmacological treatment of breastfeeding women with depressive disorders was achieved.

RESULTS

Four key research areas were delineated: (1) The imperative to address depressive and anxiety disorders during lactation, pinpointing the risks linked to untreated maternal depression during this period. (2) The evaluation of the cumulative risk of unfavorable infant outcomes associated with exposure to antidepressants or anxiolytics. (3) The long-term impact on infants' cognitive development or behavior due to exposure to these medications during breastfeeding. (4) The assessment of pharmacological interventions for opioid abuse in lactating women diagnosed with depressive disorders.

CONCLUSIONS

The ensuing recommendations were as follows: Recommendation 1: Depressive and anxiety disorders, as well as their pharmacological treatment, are not contraindications for breastfeeding. Recommendation 2: The Panel advocates for the continuation of medication that has demonstrated efficacy during pregnancy. If initiating an antidepressant during breastfeeding is necessary, drugs with a superior safety profile and substantial epidemiological data, such as SSRIs, should be favored and prescribed at the lowest effective dose. Recommendation 3: For the short-term alleviation of anxiety symptoms and sleep disturbances, the Panel determined that benzodiazepines can be administered during breastfeeding. Recommendation 4: The Panel advises against discontinuing opioid abuse treatment during breastfeeding. Recommendation 5: The Panel endorses collaboration among specialists (e.g., psychiatrists, pediatricians, toxicologists), promoting multidisciplinary care whenever feasible. Coordination with the general practitioner is also recommended.

Comparative analysis of low-dose bupivacaine and ropivacaine combined with spinal-epidural anesthesia in cesarean sections for pregnant women with coexisting mental illness

OBJECTIVE

To analyze the application effects of low-dose bupivacaine and ropivacaine combined with epidural anesthesia.

METHODS

The primary outcome measure was the anesthesia effect, assessed by the excellent anesthesia rate. Secondary outcomes included the occurrence of adverse reactions, blood pressure, and serum prolactin levels at different time points. The anesthesia effect, serum prolactin levels, occurrence of adverse reactions, and MAP at various time points [before anesthesia (T0), 5 min after anesthesia (T1), at the start of surgery (T2), at delivery of the fetus (T3), and at closure of the abdomen (T4)] were compared between the two groups.

RESULTS

① Anesthesia effect: The excellent anesthesia rate was 71.88% in the control group and 93.94% in the observation group, with a significantly higher rate in the observation group than in the control group (p = 0.017). ② Serum prolactin levels: The serum prolactin levels in both groups increased significantly after surgery compared to before surgery (p < 0.001); however, there was no statistically significant difference in serum prolactin levels between the two groups before and after surgery (p = 0.651). ③ Occurrence of adverse reactions: The occurrence rate of adverse reactions was 28.13% in the control group and 9.09% in the observation group, with a significantly lower rate in the observation group than in the control group (p = 0.048).

CONCLUSION

In cesarean sections for pregnant women with coexisting mental illness, low-dose ropivacaine demonstrates significantly better anesthesia efficacy, blood pressure stability, and anesthesia safety compared to low-dose bupivacaine. Both low-dose bupivacaine and ropivacaine result in increased prolactin levels postpartum.

Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

Addressing Pregnancy And Parenting In Mental Health Care: Perspectives Of Women With Serious Mental Illness

Women living with serious mental illness (SMI) are at increased risk for adverse pregnancy and parenting outcomes. However, little is known about the experiences and preferences of women with SMI related to addressing pregnancy and parenting with their mental health providers. We conducted semistructured interviews with twenty-two reproductive-age cisgender women patients living with SMI. Participants characterized discussions about pregnancy and medication teratogenicity with their mental health providers as limited or unsatisfactory. Participants' openness to discussing pregnancy varied by topic and its perceived relevance to their individual circumstances, and it hinged on participants' trust in their providers. Participants characterized discussions about parenting with their mental health providers as helpful and identified additional opportunities for parenting support. Our findings highlight critical gaps in the delivery of information, support, and resources that can inform efforts to increase providers' capacity to address pregnancy and parenting with women living with SMI.

Are Providers Adequately Screening for Anxiety Symptoms During Pregnancy?

OBJECTIVE

To examine the difference in prevalence of self-reported anxiety symptoms throughout pregnancy compared to clinical diagnosis of an anxiety disorder by a provider.

DESIGN

Secondary data analysis of a prospective cohort study of 50 pregnant individuals.

SETTING/LOCAL PROBLEM

Pregnant individuals commonly experience heightened anxiety symptoms, which are associated with adverse perinatal outcomes. However, a diagnosis of an anxiety disorder by a health care provider is less common, which may result in insufficient mental health intervention.

PARTICIPANTS

Pregnant individuals were recruited at their first prenatal appointment and followed until birth.

INTERVENTION/MEASUREMENTS

We examined anxiety symptoms using the Edinburgh Postnatal Depression Scale Anxiety subscale. We conducted a medical record review to examine if pregnant individuals were clinically diagnosed with an anxiety disorder.

RESULTS

Based on an Edinburgh Postnatal Depression Scale Anxiety subscale cutoff score of ≥5, 40% (n = 20) of individuals experienced anxiety symptoms during pregnancy. However, only 16% (n = 8) of participants were diagnosed with an anxiety disorder by a health care provider.

CONCLUSION

Anxiety symptoms are prevalent throughout pregnancy and may be underdiagnosed by health care providers. An intervention to increase clinical diagnosis of an anxiety disorder and subsequent referral to a mental health specialist may be indicated.

Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

Diagnosed behavioral health conditions during the perinatal period among a commercially insured population by race/ethnicity, 2008-2020

Objective

We sought to examine trends in diagnosed behavioral health (BH) conditions [mental health (MH) disorders or substance use disorders (SUD)] among pregnant and postpartum individuals between 2008-2020. We then explored the relationship between BH conditions and race/ethnicity, acknowledging race/ethnicity as a social construct that influences health disparities.

Methods

This study included delivering individuals, aged 15-44 years, and continuously enrolled in a single commercial health insurance plan for 1 year before and 1 year following delivery between 2008-2020. We used BH conditions as our outcome based on relevant ICD 9/10 codes documented during pregnancy or the postpartum year.

Results

In adjusted analyses, white individuals experienced the highest rates of BH conditions, followed by Black, Hispanic, and Asian individuals, respectively. Asian individuals had the largest increase in BH rates, increasing 292%. White individuals had the smallest increase of 192%. The trend remained unchanged even after adjusting for age and Bateman comorbidity score, the trend remained unchanged.

Conclusions

The prevalence of diagnosed BH conditions among individuals in the perinatal and postpartum periods increased over time. As national efforts continue to work toward improving perinatal BH, solutions must incorporate the needs of diverse populations to avert preventable morbidity and mortality.

Drug-induced fetal and offspring disorders, beyond birth defects

Studies on drug utilization in western countries disclosed that about nine over ten women use at least one or more drugs during pregnancy. Determining whether a drug is safe or not in pregnant women is a challenge of all times. As a developing organism, the fetus is particularly vulnerable to effects of drugs used by the mother. Historically, research has predominantly focused on birth defects, which represent the most studied adverse pregnancy outcomes. However, drugs can also alter the ongoing process of pregnancy and impede the general growth of the fetus. Finally, adverse drug reactions can theoretically damage all developing systems, organs or tissues, such as the central nervous system or the immune system. This extensive review focuses on different aspects of drug-induced damages affecting the fetus or the newborn/infant, beyond birth defects, which are not addressed here.

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.

Independent and Combined Effects of Prenatal Alcohol Exposure and Prenatal Stress on Fetal HPA Axis Development

Prenatal alcohol exposure (PAE) and prenatal stress (PS) are highly prevalent conditions known to affect fetal programming of the hypothalamic-pituitary-adrenal (HPA) axis. The objectives of this study were to assess the effect of light PAE, PS, and PAE-PS interaction on fetal HPA axis activity assessed via placental and umbilical cord blood biomarkers. Participants of the ENRICH-2 cohort were recruited during the second trimester and classified into the PAE and unexposed control groups. PS was assessed by the Perceived Stress Scale. Placental tissue was collected promptly after delivery; gene and protein analysis for 11β-HSD1, 11β-HSD2, and pCRH were conducted by qPCR and ELISA, respectively. Umbilical cord blood was analyzed for cortisone and cortisol. Pearson correlation and multivariable linear regression examined the association of PAE and PS with HPA axis biomarkers. Mean alcohol consumption in the PAE group was ~2 drinks/week. Higher PS was observed in the PAE group (p < 0.01). In multivariable modeling, PS was associated with pCRH gene expression (β = 0.006, p < 0.01), while PAE was associated with 11β-HSD2 protein expression (β = 0.56, p < 0.01). A significant alcohol-by-stress interaction was observed with respect to 11β-HSD2 protein expression (p < 0.01). Results indicate that PAE and PS may independently and in combination affect fetal programming of the HPA axis.

Potentially modifiable risk and protective factors affecting mental and emotional wellness in pregnancy

Introduction

Impaired mental and emotional wellness often co-occurs with prenatal substance use, and both affect infant socio-emotional, cognitive, language, motor, and adaptive behavioral outcomes. Guided by the modified biopsychosocial framework, this study examined the role of common substance exposures during pregnancy (i.e., alcohol and cannabis), socio-cultural factors (social support during pregnancy, adverse childhood experiences), and reproductive health factors on maternal mental health (MMH).

Methods

Data were obtained from a prospective cohort study-Ethanol, Neurodevelopment, Infant, and Child Health (ENRICH-2), and included 202 pregnant persons. Alcohol and cannabis exposures were assessed through repeated prospective interviews and a comprehensive battery of drug and ethanol biomarkers. MMH outcomes were evaluated during the third trimester through the Perceived Stress Scale, Edinburgh Depression Scale, Generalized Anxiety Disorders-7, and Post-traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders. Univariate and multivariable linear regression models evaluated significant predictors of MMH.

Results

Results of multivariable analysis indicate that both maternal adverse childhood experiences and alcohol exposure, even at low-to-moderate levels, during pregnancy were associated with poorer scores for most MMH measures, while higher level of social support and Spanish as the primary language at home (as a proxy of enculturation) had protective effects (all p's < 0.05).

Conclusion

These findings highlight the importance of assessing substance use, including periconceptional alcohol exposure, and mental health in pregnant persons as closely related risk factors which cannot be addressed in isolation. Our findings also emphasize a strong protective effect of socio-cultural factors on maternal mental and emotional wellbeing-a strong precursor to maternal-infant bonding and infant neurodevelopment.

Concerns That May Limit the Utility of Zuranolone

This Viewpoint discusses the evidence base of the US Food and Drug Administration approval of zuranolone.

Review of the Assessment and Management of Perinatal Mood and Anxiety Disorders

Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth. When poorly controlled, they are associated with worse obstetric outcomes, such as higher rates of preterm birth and unplanned cesarean delivery. They are also associated with suicide, a leading cause of perinatal maternal death. This article provides an overview of evidence-based recommendations for screening, assessment, and management of PMADs, including suicide risk assessment and management and pharmacological and nonpharmacological treatment options compatible with pregnancy and lactation. Although specialized reproductive psychiatrists can provide expert guidance for the management of PMADs, their scarcity means that most patients will not have access to this expert care and instead will seek guidance from general psychiatrists. This article provides a clinical guide for generalists that is based on the best current evidence, including recently released treatment guidelines.

Indirect comparisons of relative efficacy estimates of zuranolone and selective serotonin reuptake inhibitors for postpartum depression

AIMS

Estimate relative efficacy of zuranolone, a novel oral, Food and Drug Administration-approved treatment for postpartum depression (PPD) in adults vs. selective serotonin reuptake inhibitors (SSRIs) and combination therapies used for PPD in the United States.

MATERIALS AND METHODS

Randomized controlled trials (RCTs) for zuranolone and SSRIs, identified from systematic review, were used to construct evidence networks, linking via common comparator arms. Due to heterogeneity in placebo responses, matching-adjusted indirect comparison (MAIC) was applied, statistically weighting the zuranolone treatment arm of Phase 3 SKYLARK Study (NCT04442503) to the placebo arm of RCTs investigating SSRIs for PPD. MAIC outputs were applied in Bucher indirect treatment comparisons (ITCs) and network meta-analysis (NMA), using Edinburgh Postnatal Depression Scale (EPDS) and 17-item Hamilton Rating Scale for Depression (HAMD-17) change from baseline (CFB) on Days 3, 15, 28 (Month 1), 45, and last observation (Day 45, Week 12/18).

RESULTS

Larger EPDS CFB was observed among zuranolone-treated vs. SSRI-treated patients from Day 15 onward. Zuranolone-treated (vs. SSRI-treated) patients exhibited 4.22-point larger reduction in EPDS by Day 15 (95% confidence interval: -6.16, -2.28) and 7.43-point larger reduction at Day 45 (-9.84, -5.02) with Bucher ITC. NMA showed EPDS reduction for zuranolone was 4.52 (-6.40, -2.65) points larger than SSRIs by Day 15 and 7.16 (-9.47, -4.85) larger at Day 45. Lack of overlap between study populations substantially reduced effective sample size post-matching, making HAMD-17 CFB analysis infeasible.

LIMITATIONS

Limited population overlap between SKYLARK Study and RCTs reduced feasibility of undertaking HAMD-17 CFB ITCs and may introduce uncertainty to EPDS CFB ITC results.

CONCLUSIONS

Analysis showed zuranolone-treated patients with PPD experienced greater symptom improvement than SSRI-treated patients from Day 15 onward, with largest mean difference at Day 45. Adjusting for differences between placebo arms, zuranolone may be associated with greater PPD symptom improvement (measured by EPDS) vs. SSRIs.

Striking the Balance: Bipolar Disorder in the Perinatal Period

The authors reviewed the literature, published between 2018 and 2023, on treating bipolar disorder in the perinatal period in order to summarize current treatment perspectives. Mood episodes occur during pregnancy and there are high rates of both initial onset and recurrence in the postpartum period. Bipolar disorder itself is associated with higher risks of adverse pregnancy outcomes, including gestational hypertension, hemorrhage, cesarean delivery, and small for gestational age infants. A general principle of perinatal treatment includes maintaining psychiatric stability of the pregnant person while reducing medication exposure risk to the fetus. A variety of factors can compromise psychiatric stability, including rapid discontinuation of stabilizing medications, decreased efficacy due to physiologic changes of pregnancy, and exacerbation of underlying psychiatric illness. Psychosocial interventions include optimizing sleep, increasing support, and reducing stress. The American College of Obstetricians and Gynecologists recommends against discontinuing or withholding medications solely due to pregnancy or lactation status. Individualized treatment involves a discussion of the risks of undertreated bipolar disorder weighed against the risks of individual medication choice based on available evidence regarding congenital malformations, adverse neonatal and obstetrical events, and neurodevelopmental outcomes. Valproate is not a first-line treatment due to higher risks. Data are lacking on safety for many newer medications. The authors review current safety data regarding lithium, lamotrigine, and antipsychotics, which are the most commonly used treatments for managing bipolar disorder in the perinatal period. Due to physiologic changes during pregnancy, frequent therapeutic drug monitoring and dose adjustments are required.