Postpartum psychiatric disorders

A Cross-Sectional Study Examining the Association between Physical Activity and Perinatal Depression

Background and Objectives: International organisations recommend that women without illness should have regular moderate-intensity physical exercise throughout their pregnancy and postpartum period as a measure to prevent possible pathologies in both the mother and the newborn. Physical activity during pregnancy reduces the likelihood of depression during pregnancy and after childbirth, benefiting both the pregnant woman and the foetus. However, most pregnant women are known to be inactive. The Pregnancy Physical Activity Questionnaire (PPAQ) analyses the level of physical activity of pregnant women. These data are correlated with the variable depression, for which the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy was used. Materials and Methods: The research employed a cross sectional study design on ninety-nine pregnant women. Results: The data on physical activity in relation to depression in those pregnant women who had not previously suffered from depression were 719.29 METS min/wk compared with 624.62 METS min/wk in those who had. And for pregnant women who suffered from depression at the time of the study, their physical activity was 698.25 METS min/wk, while those who did not suffer from depression reached 826.57 METS. Conclusions: Pregnant women without depression are much more active. A favourable employment situation or a high level of education is directly related to higher physical activity. Physical activity and higher energy expenditure occur at home, as opposed to activity carried out as transport, exercise or at work.

Inpatient mother-and-child postpartum psychiatric care: Factors associated with improvement in maternal mental health

Purpose

This study assessed the underexplored factors associated with significant improvement in mothers’ mental health during postpartum inpatient psychiatric care.

Methods

This study analyzed clinical improvement in a prospective cohort of 869 women jointly admitted with their infant to 13 psychiatric Mother-Baby Units (MBUs) in France between 2001 and 2007. Predictive variables tested were: maternal mental illness (ICD-10), sociodemographic characteristics, mental illness and childhood abuse history, acute or chronic disorder, pregnancy and birth data, characteristics and mental health of the mother's partner, and MBU characteristics.

Results

Two thirds of the women improved significantly by discharge. Admission for 25% was for a first acute episode very early after childbirth. Independent factors associated with marked improvement at discharge were bipolar or depressive disorder, a first acute episode or relapse of such an episode. Schizophrenia, a personality disorder, and poor social integration (as measured by occupational status) were all related to poor clinical outcomes.

Discussion

Most women improved significantly while under care in MBUs. Our results emphasize the importance of the type of disease but also its chronicity and the social integration when providing postpartum psychiatric care.

The evolutionary context of postnatal depression

"Postnatal depression" denotes the syndrome of dysphoria, debility, and anxiety that follows childbirth in about 10-20% of women (as variously estimated). Its etiology is seen to be lodged in a variety of psychosocial as well as biological factors, among which the isolating and pressured culture of contemporary society (especially for women/mothers) is commonly singled out as a powerful precipitator. This view is extended here through the evolutionary perspective which casts maternal distress as a set of adaptive responses with the function, in ancestral environments, of soliciting support for a mother who feels that her maternal responsiveness may be threatened. As continuous caretaking of the infant is the active expression of evolved maternal responsiveness, departures from this pattern result in anxiety and distress that seek resolution. Manifestations of maternal distress in contemporary society are dysfunctional, however, since the present social structure does not provide spontaneous and immediate support that can spring forth within small, closely knit social units. Furthermore, for present-day mothers distress is self-perpetuating since the ingrained tendency toward continuing responsiveness rarely finds practical expression and is thus converted into anxious vigilance and depression. This view generates the hypothesis that the emotional and cognitive contents of maternal vigilance are associated with the needs of the infant and will therefore be focused on crying and feeding. A number of qualitative studies of women's experiences during the postpartum bear out this prediction and support the feasibility of the evolutionary hypothesis of "postnatal depression" as a set of adaptive responses, now out of place in a novel environment.

Bonding, postpartum dysphoria, and social ties : A speculative inquiry

Since the late 1970s, disruptions and "failure" of maternal-infant bonding have been causally linked to postpartum depression. Part I of this paper examines the grounds for this connection while tracing the ramifications of bonding theory (Klaus and Kennell 1976) through obstetrics, pediatrics, and psychiatry, as well as in the (mis)representations of it in the popular media. This discussion resolves into a view of maternal attachment as a long-term development progressively established through intensive mother-infant interaction. The forms of this interaction are phylogenetically determined, albeit culturally and personally mediated. Flowing from this premise, Part II of the paper casts postpartum depression as an adaptive response to threat (from whatever cause) to adequate mothering, and develops an argument for the evolutionary role of enacted social ties in the establishment of maternal responsiveness.

Dietary supplements for preventing postnatal depression

BACKGROUND

Postnatal depression is a medical condition that affects many women and the development of their infants. There is a lack of evidence for treatment and prevention strategies that are safe for mothers and infants. Certain dietary deficiencies in a pregnant or postnatal woman's diet may cause postnatal depression. By correcting these deficiencies postnatal depression could be prevented in some women. Specific examples of dietary supplements aimed at preventing postnatal depression include: omega-3 fatty acids, iron, folate, s-adenosyl-L-methionine, cobalamin, pyridoxine, riboflavin, vitamin D and calcium.

OBJECTIVES

To assess the benefits of dietary supplements for preventing postnatal depression either in the antenatal period, postnatal period, or both.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013).

SELECTION CRITERIA

Randomised controlled trials, involving women who were pregnant or who had given birth in the previous six weeks, who were not depressed or taking antidepressants at the commencement of the trials. The trials could use as intervention any dietary supplementation alone or in combination with another treatment compared with any other preventive treatment, or placebo, or standard clinical care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed the risk of bias for the two included studies. Two review authors extracted data and the data were checked for accuracy.

MAIN RESULTS

We included two randomised controlled trials.One trial compared oral 100 microgram (µg) selenium yeast tablets with placebo, taken from the first trimester until birth. The trial randomised 179 women but outcome data were only provided for 85 women. Eighty-three women were randomised to each arm of the trial. Sixty-one women completed the selenium arm, 44 of whom completed an Edinburgh Postnatal Depression Scale (EPDS). In the placebo arm, 64 women completed the trial, 41 of whom completed an EPDS. This included study (n = 85) found selenium had an effect on EPDS scores but did not reach statistical significance (P = 0.07). There was a mean difference (MD) of -1.90 (95% confidence interval (CI) -3.92 to 0.12) of the self-reported EPDS completed by participants within eight weeks of delivery. There was a high risk of attrition bias due to a large proportion of women withdrawing from the study or not completing an EPDS. This included study did not report on any of the secondary outcomes of this review.The other trial compared docosahexanoic acid (DHA) and eicosapentaenoic acid (EPA) with placebo. The trial randomised 126 women at risk of postpartum depression to three arms: 42 were allocated to EPA, 42 to DHA, and 42 to placebo. Three women in the EPA arm, four in the DHA arm, and one woman in the placebo arm were lost to follow-up. Women who were found to have major depressive disorder, bipolar disorder, current substance abuse or dependence, suicidal ideation or schizophrenia at recruitment were excluded from the study. The women who discontinued the intervention (five in the EPA arm, four in the DHA arm and seven in the placebo arm) were included in the intention-to-treat analysis, while those who were lost to follow-up were not. Women received supplements or placebo from recruitment at a gestational age of 12 to 20 weeks until their final review visit six to eight weeks postpartum. The primary outcome measure was the Beck Depression Inventory (BDI) score at the fifth visit (six to eight weeks postpartum). No benefit was found for EPA-rich fish oil (MD 0.70, 95% CI -1.78 to 3.18) or DHA-rich fish oil supplementation (MD 0.90, 95% CI -1.33 to 3.13) in preventing postpartum depression. No difference was found in the effect on postnatal depression comparing EPA with DHA (MD -0.20, 95% CI -2.61 to 2.21). No benefit or significant effect was found in terms of the secondary outcomes of the presence of major depressive disorder at six to eight weeks postpartum, the number of women who commenced antidepressants, maternal estimated blood loss at delivery or admission of neonates to the neonatal intensive care unit.

AUTHORS' CONCLUSIONS

There is insufficient evidence to conclude that selenium, DHA or EPA prevent postnatal depression. There is currently no evidence to recommend any other dietary supplement for prevention of postnatal depression.

Newborn gender as a predictor of postpartum mood disturbances in a sample of Swedish women

Postpartum depression (PPD) is a condition that affects about 10% of newly delivered women. The aim of this study was to examine the possible association between offspring gender and risk for development of PPD in Sweden. The study was undertaken as part of the UPPSAT project, a population-based longitudinal study in Uppsala, Sweden. From May 2006 to June 2007, women who gave birth at Uppsala University Hospital and fulfilled the inclusion criteria were asked to participate. The participating women filled out, at three points during the first 6 months after delivery, questionnaires containing the Edinburgh Postnatal Depression Scale as well as questions concerning various lifestyle factors, medical history, breast feeding habits, social support parameters, and diet factors. No significant difference in risk of PPD in relation to baby gender could be shown 6 weeks and 6 months after delivery. However, women who gave birth to a male offspring had a significantly higher risk of self-reported depressive symptomatology 5 days after delivery. The association remained statistically significant after adjustment for possible confounders in a logistic regression model. This longitudinal study demonstrates that, in Sweden, the gender of the offspring is not associated with a higher risk for self-reported postpartum depression in the mother 6 weeks or 6 months after delivery. The birth of a baby boy, however, gives the mother a higher risk of postpartum blues 5 days after delivery.

Seasonality patterns in postpartum depression

OBJECTIVE

To investigate the possible association between postpartum depressive symptoms and season of delivery.

STUDY DESIGN

During 1 year, delivering women in the Uppsala University Hospital were asked to participate in the study by filling out 3 postpartum questionnaires containing the Edinburgh Postnatal Depression scale and questions assessing life style, medical history, breastfeeding, and social support.

RESULTS

Two thousand three hundred eighteen women participated. Women delivering in the last 3 months of the year had a significantly higher risk of self-reported depressive symptomatology both at 6 weeks (odds ratio, 2.02, 95% confidence interval, 1.32-3.10) and at 6 months after delivery (odds ratio, 1.82, 95% confidence interval, 1.15-2.88), in comparison to those delivering April-June, both before and after adjustment for possible confounders.

CONCLUSION

Women delivering during the last quartile of the year had a significantly higher risk for depressive symptoms 6 weeks and 6 months postpartum and would thus benefit from a closer support and follow-up after delivery.

Psychiatric disorders in pregnancy

The care and treatment of women with psychiatric disorders in pregnancy is both challenging and complex. The decision to treat or not treat can pose a risk to the mother, the developing fetus or infant and the pregnancy outcome. Treatment options can be both pharmacologic and non-pharmacologic. The risk and benefit of treatment is a shared decision between the woman and her obstetrical and mental health providers. There is no definitive answer to the optimal treatment of psychiatric disorders in pregnancy. The ideal treatment would minimize the risk to the developing fetus and enable the mother to have few or no psychiatric symptoms during pregnancy.

Perinatal depression: hiding in plain sight

OBJECTIVE

To promote prompt identification and treatment ofperinatal depression and enhance preventive care for women at risk.

METHODS

Using MEDLINE and PubMed searches, we reviewed the recent research on the origins, course, and consequences of pregnancy-related depression.

RESULTS

Depressive disorders are more common in pregnancy and postpartum than widely assumed, and there is no predictable protective effect of pregnancy. Relapse rates are high, and the postpartum period represents a time of increased vulnerability to depression.

CONCLUSION

Early identification and treatment ofperinatal depression will minimize morbidity and mortality for the woman, the child, and the family.

Immigrant Asian Indian women and postpartum depression

OBJECTIVE

To determine the incidence of postpartum depressive symptomatology in a sample of immigrant Asian Indian women and to establish whether cultural factors such as arranged marriage or gender of the newborn are associated with differences in depression scores.

DESIGN

Quantitative, descriptive study.

SETTING

Ten private obstetric and pediatric offices in Northern California.

PARTICIPANTS

A convenience sample of 58 self-selected immigrant Asian Indian women between 2 weeks and 12 months postpartum.

MAIN OUTCOME MEASURE

Depressive symptomatology as measured by the 35-item self-report Postpartum Depression Screening Scale.

RESULTS

There was a minor depressive symptomatology rate of 28% and an additional major depressive symptomatology rate of 24%. No differences in depression scores were found with regard to arranged marriage or the gender of the newborn.

CONCLUSIONS

Findings suggest that Asian Indian women living in the United States are just as likely to experience postpartum depressive symptomatology as White women. Therefore, it is critical to identify and refer women at risk for postpartum depression to ensure they do not become part of the 50% who remain undiagnosed. Health care providers need to become cognizant of the potential for postpartum depression and become skilled in the detection of this mood disorder.

A Review of Physical Activity Patterns in Pregnant Women and Their Relationship to Psychological Health

Regular physical activity contributes positively to physical and psychological health. Adverse consequences of inactivity may be an especially important problem among pregnant women. Up to 60% are inactive during pregnancy. This review found consistent evidence that physical activity is reduced during pregnancy; however, few investigators have sought to quantify physical activity patterns among pregnant women using well validated measures. Some of the barriers to physical activity during pregnancy, such as depression, anxiety and fatigue, have been shown to be attenuated by regular exercise performed by non-pregnant samples. There is a need to better understand the relationships between these factors and physical activity during pregnancy. Available retrospective and prospective results suggest that both leisure time and work-related physical activities are decreased across pregnancy. Intensity and duration decrease both during pregnancy compared with pre-pregnancy and in the third trimester compared with the first. There is a need for well designed longitudinal investigations that document pregnancy-related changes in physical activity at frequent intervals during pregnancy using validated and more precise measures of physical activity. Reductions in physical activity and a worsening mood are common during pregnancy. If the relationship between physical inactivity and mood disturbances is indeed observed and maintained during pregnancy, then decreases in physical activity in the third trimester would be expected to result in a worsening mood. In recent years, increased attention has been paid to antenatal mood disturbances, and this research has yielded a host of important findings. Prior correlational and experimental research with non-pregnant samples has demonstrated a consistent relationship between physical inactivity and mood disturbances. Whether this relationship occurs among pregnant women and/or is maintained as women progress during pregnancy is uncertain. Prior investigations have revealed that there is higher rate of mood disturbance during pregnancy than following pregnancy but little is known about the mechanisms that cause these mood disturbances. It is important to better understand changes in mood with pregnancy because mood disturbances can have major negative consequences for a pregnant woman. The major adverse consequences of depression among pregnant women are largely the same as those of non-pregnant individuals. Only six investigations have quantified the relationship between changes in physical activity and changes in mood during pregnancy. The available evidence suggests that inactivity is associated with worse mood. Additional research into this topic is warranted due to the limited number of published papers and the design and methodology limitations of these investigations.

The Many Faces of Postpartum Depression

OBJECTIVE

To provide a profile of women suffering from major postpartum depression as assessed by the Postpartum Depression Screening Scale (PDSS).

DESIGN

A secondary analysis conducted on a portion of the data collected from an earlier psychometric testing of the PDSS.

SETTING

Private practice in the San Francisco Bay Area of a marriage and family therapist specializing in perinatal mood disorders.

PARTICIPANTS

One hundred thirty-three women who were diagnosed with major postpartum depression.

INTERVENTION

Each mother completed the PDSS followed by a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic interview.

MAIN OUTCOME MEASURE

Seven dimensions of postpartum depression: sleeping/eating disturbances, anxiety/insecurity, emotional lability, mental confusion, loss of self, guilt/shame, and suicidal thoughts as measured by the PDSS.

RESULTS

Scores on all seven dimensions of the PDSS were elevated. The three top dimensions were emotional lability, mental confusion, and anxiety/insecurity. The mean total PDSS score of 120 was well beyond the recommended cutoff score of 80 for a positive screen for major postpartum depression.

CONCLUSION

Clinicians who come in contact with new mothers need to be alert to the range of possible symptoms that postpartum depressed mothers may experience so that these women are not left to suffer in silence.

Prognosis of postpartum psychiatric disorders in a Turkish sample

Objective The postpartum period represents a time of increased risk for psychiatric disorders. Postpartum depression is especially very common. Many aetiological risk factors have been reported for postpartum psychiatric disorders. The purpose of this study was to evaluate the postpartum psychiatric disorders in a Turkish sample and discuss their course. Methods The files of 6000 inpatients who were admitted to Gazi University School of Medicine Psychiatry Department were evaluated retrospectively, and 67 patients were chosen whose psychiatric illness had began puerperally. These patients were grouped according to age of onset of the illness, number of episodes and the type of these episodes, their postpartum psychiatric diagnoses and illness prognosis. Results Of 6000 patients, 67 (1.11%) were diagnosed as having a postpartum psychiatric disorder: 56.7% (n=38) were diagnosed as having a postpartum psychotic disorder, while 35.8% (n=24) as having an affective disorder. Forty-seven patients (70.1%) received a diagnosis of major psychiatric disorder during their follow-up. Conclusion These results show that postpartum diagnoses may show a chronic course and cause a life-time psychiatric illness and therefore patients should be monitored carefully for psychotic symptoms even after the acute period is over.

Psychiatric side effects of indomethacin in parturients

PURPOSE

To examine the central nervous system side effects of the non-steroidal anti-inflammatory drug (NSAID) indomethacin in a case-series of obstetric patients.

METHODS

The hospital records of patients experiencing any postpartum complication between 1994 and 1999 were reviewed for adverse drug reactions (ADR) attributed to indomethacin. Additional cases of indomethacin-induced adverse effects were identified through reports to the nursing administration and the Saskatchewan ADR reporting program. The Naranjo ADR probability scale was applied to all cases.

RESULTS

Thirty-two patients experienced a psychiatric reaction after receiving indomethacin for postpartum pain. The symptoms were often severe and included dizziness, anxiety, fear, agitation, affective lability, depersonalization, paranoia, and hallucinations. There was no past psychiatric history documented in any of the cases.

CONCLUSION

This study identifies a possible ADR to indomethacin occurring in postpartum patients. Whether the vulnerability to these neuropsychiatric reactions is randomly distributed or if parturients are at increased risk is yet to be determined. Proposed mechanisms of these side effects include a postpartum dopamine supersensitivity exacerbated by prostaglandin inhibition as well as a structural similarity between serotonin and indomethacin. The severity of the reactions to indomethacin in parturients and the potential for these disturbing psychiatric side effects to compromise the safety of both mother and infant have led to the use of alternative analgesics including different classes of NSAIDs for this population at our institution.

Postdelivery screening for postpartum depression

OBJECTIVE

Postpartum depression (PPD) is a serious psychiatric disorder affecting 10% to 20% of women after childbirth. Research has shown that systematic screening for PPD using self-report questionnaires helps improve the identification of PPD and expedite treatment. Most studies on PPD screening have been conducted in the second and third postpartum months; little is known about whether PPD screening can be carried out on the days immediately after delivery.

METHODS

A prospective cohort of 145 women completed the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory (BDI), and General Health Questionnaire (GHQ) within 2 days of delivery. Six weeks after delivery, the participants were interviewed by a psychiatrist, who used the Structured Clinical Interview for DSM-III-R (SCID, nonpatient version) to establish the diagnosis. The psychometric performance of the EPDS, BDI, and GHQ in detecting PPD was assessed using the SCID diagnosis as the gold standard.

RESULTS

When the cutoffs of the EPDS, BDI, and GHQ were lowered to achieve a sensitivity of 80%, the positive predictive values of these scales were to 13%, 18%, and 21%, respectively. When the cutoffs were raised to achieve a positive predictive value of 50%, the sensitivity rates were 6% (EPDS), 14% (GHQ), and 36% (BDI).

CONCLUSIONS

When commonly used depression rating scales were administered to identify PPD immediately after delivery, their psychometric properties were unsatisfactory. Healthcare providers should not screen for PPD in the first few days after delivery.

A controlled study of postpartum depression among Nepalese women: validation of the Edinburgh Postpartum Depression Scale in Kathmandu

OBJECTIVES

To measure the prevalence of depression amongst postpartum and non-postpartum Nepalese women in Kathmandu using the Edinburgh Postpartum Depression Scale (EPDS) and to assess the ease of use and validity of the scale compared with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for major depression.

METHODS

We screened 100 women 2-3 months post-delivery and 40 control women using the EPDS. All those who screened positive for depression and 20% of the negatives also underwent a structured interview to assess depression by DSM-IV criteria.

RESULTS

Predictive errors were minimized by using an EPDS score > or =13 to define depression. Using this threshold, there was no difference in depression prevalence between postpartum women (12%) and the control group (12.5%) (Fisher's exact test, P > 0.05). Compared with DSM-IV, the sensitivity, specificity and positive predictive values were 100, 92.6 and 41.6%, respectively.

CONCLUSIONS

The prevalence of postpartum depression (PPD) in Nepalese women and the validity and ease of use of the EPDS in the setting of a postnatal clinic in Kathmandu are all surprisingly similar to the results of numerous studies in developed countries. Despite poor living conditions, PPD is no more common than the background depression rate amongst Nepalese women. It can be reliably detected by trained clinical nurses using the EPDS screening test. These results may have implications for the planning of mental health resources for women in other developing countries.

Diverse actions of ovarian steroids in the serotonin neural system

All of the serotonin-producing neurons of the mammalian brain are located in 10 nuclei in the mid- and hindbrain regions. The cells of the rostal nuclei project to almost every area of the forebrain and regulate diverse neural processes from higher order functions in the prefrontal cortex such as integrative cognition and memory, to limbic system control of arousal and mood, to diencephalic functions such as pituitary hormone secretion, satiety, and sexual behavior. The more caudal serotonin neurons project to the spinal cord and interact with numerous autonomic and sensory systems. All of these neural functions are sensitive to the presence or absence of the ovarian hormones, estrogen and progesterone. We have shown that serotonin neurons in nonhuman primates contain estrogen receptor beta and progestin receptors. Thus, they are targets for ovarian steroids which in turn modify gene expression. Any change in serotoninergic neural function could be manifested by a change in any of the projection target systems and in this manner, serotonin neurons integrate steroid hormone information and partially transduce their action in the CNS. This article reviews the work conducted in this laboratory on the actions of estrogens and progestins in the serotonin neural system of nonhuman primates. Comparisons to results obtained in other laboratory animal models are made when available and limited clinical data are referenced. The ability of estrogens and progestins to alter the function of the serotonin neural system at various levels provides a cellular mechanism whereby ovarian hormones can impact cognition, mood or arousal, hormone secretion, pain, and other neural circuits.

Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes

OBJECTIVE

The purpose of this study was to examine if depressive symptomatology in pregnancy is associated with adverse obstetric and neonatal outcomes.

METHOD

In a prospective observational study, 959 women were followed up longitudinally from early pregnancy to postpartum. The level of depression was measured at baseline (first antepartum visit) and in late pregnancy using the Beck Depression Inventory (BDI). Adverse obstetric and neonatal outcomes were recorded at delivery.

RESULTS

Depression in late pregnancy was associated with increased risk of epidural analgesia (33% vs. 19%, p =.01, adjusted RR = 2.56, 95% CI 1.24-5.30), operative deliveries (caesarean sections and instrumental vaginal deliveries) (39% vs. 27%, p =.02, adjusted RR = 2.28, 95% CI 1.15-4.53), and admission to neonatal care unit (24% vs. 19%, p =.03, adjusted RR = 2.18, 95% CI 1.02-4.66). These effects remained significant even when controlled for potential confounders, such as antepartum complications.

CONCLUSION

Previous studies have shown that antepartum anxiety or stress was associated with growth retardation, premature delivery, and epidural analgesia. Our findings add to this body of evidence, which together suggest an adverse impact of antepartum psychological morbidity on maternal and neonatal well-being.

Perinatal depression: a randomized controlled trial of an antenatal education intervention for primiparas

BACKGROUND

Depression can be an unexpected and distressing companion for a woman during the major life transition of becoming a mother for the first time. Researchers now demonstrate that approximately 50 percent of women will experience perinatal distress. Therefore, the etiology and management of perinatal depression is essential for a quality care of childbearing women. The objectives of this study were to develop an education intervention tailored to the information needs of primiparous women about perinatal depression, to deliver this intervention antenatally, and to conduct a randomized controlled trial to determine the effect of the antenatal education intervention in the reduction of postnatal depression.

METHOD

A prospective, randomized controlled trial of the education intervention (n = 206) was conducted at three sites in Australia. The outcome of changes in mood state was measured by the Profile of Mood States questionnaire once antenatally (12-28 wk), and twice postnatally (8-12 and 16-24 wk); social support and demographic data were also collected. The education package was administered to the intervention group at the antenatal assessment of mood.

RESULTS

A significant and steady reduction in scores (overall and on the subscales) was observed over time for both groups that showed significant improvement in symptoms of depression. No difference was detected when comparing the intervention group with the control group. Additional multivariate regression analyses revealed no relevant influence of social support or demographic variables.

CONCLUSIONS

Women in both the study and control groups were more depressed antenatally than postnatally. The finding that the education intervention made no difference challenges the two strongly held tenets of health education in childbearing women-that depression can be reduced through education and that antenatal education interventions can endure into the postnatal period.

Characteristics and treatment of women with antenatal and postpartum depression

OBJECTIVE

Investigations of the efficacy of treatment for non-psychotic pregnancy-related mood disorders are scarce. Thus, a prospective, longitudinal study of six months duration, involving ninety-six index cases and forty-five healthy women as a reference group, was implemented to determine the response of mood, parenting stress and dyadic adjustment to an eclectic management.

METHOD

In this naturalistic study, the index cases were offered treatment consistent with their symptoms, context, and level of compliance. All women received individual psychotherapy combining strategies from Interpersonal and Cognitive Behavioral Psychotherapy and/or Marital Interventions and Pharmacology. Rating scales (Dyadic Adjustment Scale, Hamilton Rating Scale for Depression, Edinburgh Postnatal Depression Scale, Child Stress Inventory) scored monthly, were used to measure the response to treatment over time.

RESULTS

Depressive symptoms are generally alleviated by the second to third month of treatment. Dyadic discord accentuated by traditional sex role expectations and child care stress exacerbated by low self-esteem persisted throughout the trial at levels significantly different from the untreated reference group.

CONCLUSIONS

Short-term interventions are cost-effective for the relief of mood disorders. However, creative solutions, during an era of economic restraints, are required to extend treatment sufficiently to address couple conflicts and facilitate the transition to parenthood for index cases.

Postnatal depression: a study of mothers in the metropolitan area of Perth, Western Australia

This paper sets out the extent to which postnatal depression (PND) existed within the Perth metropolitan area of Western Australia in 1993/94. More importantly, the phenomenon of PND, from the mothers' perspective, is described. The paper is based on a two-stage research carried out on PND from 1993 to 1994. In the first stage, the Edinburgh Postnatal Depression Scale (EPDS) was used to screen mothers for PND. A random sample of 399 women showed 72 (18 percent) were found to be suffering from a depressive illness of varying severity. The second stage of the study used a grounded theory approach. Fifteen mothers with PND from the group screened were interviewed in their own homes. A schema, developed from the data, revealed that the main problems of the mothers was vulnerability. Support played a pivotal role in the transition from PND to stable motherhood. There was a long and short circuit followed, according to the availability and non-availability of support.

Incidence of postnatal depression in Malaysian women

OBJECTIVE

To determine the incidence of postnatal depression of Malaysias women at 6 week postpartum and a survey of their sociocultural practices.

METHODS

A hundred and fifty-four women who were 6 weeks postpartum attending the postnatal clinic between May and July 1995 at Maternal and Child Health Clinic, Seremban, Malaysia. Maternal socio-demography, depression by Edinburgh Postnatal Depression Scale (EPDS), postnatal care and practices e.g. pantang larang (prohibited behaviour and practices), diet and partnering were evaluated.

RESULTS

Postnatal depression was 3.9%. Indians had the highest rate at 8.5% as compared to Malays (3.0%) and none in Chinese (p < 0.05). There were no demographic differences in the study groups. Average score of EPDS was 4.05 which ranged from 0 to 20. During the confinement 85.7% of women took special diet; 64.3% followed pantang larang and 78.8% had someone to look after them. The incidence of postnatal depression is low in Malaysia at 3.9%. Majority of Malaysian women still observed the traditional postnatal beliefs and practices.

Ovarian steroid regulation of tryptophan hydroxylase mRNA expression in rhesus macaques

Progesterone (P) stimulates prolactin secretion through an unknown neural mechanism in estrogen (E)-primed female monkeys. Serotonin is a stimulatory neurotransmitter in prolactin regulation, and this laboratory has shown previously that E induces progestin receptors (PR) in serotonin neurons. Therefore, we questioned whether E and/or E+P increased serotonin neural function. The expression of mRNA for tryptophan hydroxylase (TPH) was examined in ovariectomized (spayed) control, E-treated (28 d), and E+P-treated monkeys (14 d E and 14 d E+P) using in situ hybridization and a 249 bp TPH cRNA probe generated with RT-PCR (n = 5 animals/group). Densitometric analysis of film autoradiographs revealed a ninefold increase in TPH mRNA in E-treated macaques compared to spayed animals (p < 0.05). With supplemental P treatment, TPH mRNA signal was increased fivefold over spayed animals (p < 0.05), but was not significantly different compared to E-treated animals. These results were verified by grain counts from photographic emulsion-coated slides. There were significantly higher single-cell levels of TPH mRNA in serotonergic neurons of the dorsal raphe in E- and E+P-treated groups (p < 0.05). These data indicate that E induces TPH gene expression in nonhuman primates and that the addition of P has little additive effect on TPH gene expression. Thus, the action of P on prolactin secretion is probably not mediated at the level of TPH gene transcription. However, because P increases raphe serotonin content in E-primed rodents, the possibility remains that P may have other actions on post-translational processing or enzyme activity.

Childhood sexual abuse: a risk factor for postpartum depression?

While the link between childhood sexual abuse and adult psychiatric disorder has been documented, such research has not looked at any association with postpartum depression. Admissions to the Mercy Mother-Baby Unit are reviewed with respect to a possible link, with case examples presented. An aetiological model is proposed and clinical implications are highlighted.

Screening for post-partum depression in a community sample

OBJECTIVE

This study undertook to estimate the prevalence of post-partum depression in the community by means of telephone screening. Demographic correlates of post-partum depression were also investigated.

METHOD

The sample was identified through two community health centres. Over a period of 17 months, 1559 childbearing women were screened at six weeks post-partum, using the ten-item Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

The prevalence of post-partum depression was estimated to be 6.2%, using a cut point of 10 on the EPDS, and 3.4% using the more stringent cut point of 12. Women who were not working or those with lower occupational status, were at greater risk for depression. Recent immigrants, particularly those who were not working or who had given birth to a second child, were also at higher risk.

CONCLUSION

Telephone screening for post-partum depression is feasible, and can aid in the identification of women at risk.

Does recombinant human erythropoietin not only treat anemia but reduce postpartum (emotional) distress as well?

Based on the established rhEPO treatment of anemia in endstage renal failure, which results in improved quality of life, and on the clinical observation that patients with postpartum anemia treated with rhEPO seemed to gain a more stable mood, we inferred that there is a beneficial side-effect of rhEPO on postpartum blues. The aim of this study was to test the hypotheses 1) that postpartum anemia aggravates, and 2) that treatment of postpartum anemia with rhEPO reduces maternity blues. The results show that on the fifth day postpartum anemic patients score consistently worse than nonanemic women on the Symptom Checklist SCL-90-R, indicating more symptoms and distress in general, and also more symptoms characteristic of maternity blues (p < 0.05). On a "Blues Questionnaire," postpartum anemia expresses itself with a reduced "well-being" (p < 0.001). Thus, our first hypothesis was verified. There were no differences by the fifth day postpartum between anemic patients receiving either rhEPO or placebo. Our second hypothesis was thus not confirmed within this limited time. We conclude as clinicians that postpartum anemia should be treated effectively to reduce distress and hence the risk for postpartum affective disorders. Follow-up studies after rhEPO treatment beyond the first week post partum are needed. In addition, in investigations on postpartum affective disorders, the hemoglobin concentration should be considered.

Childbearing in women with and without a history of affective disorder. I. Psychiatric symptomatology

Psychiatric symptoms and morbidity were examined prospectively in 34 obstetrically healthy volunteers recruited early in pregnancy. All women were free of current psychiatric disorder. Fourteen women had a history of affective disorder, and 20 had no lifetime history of any psychiatric disorder. Symptoms were assessed using both clinician- and self-administered ratings at specified points from 12 weeks of gestation through 8 months' postpartum. All women reported mild symptom elevation during pregnancy and the early puerperium, regardless of psychiatric history. The most frequently endorsed symptoms in both groups were somatic. However, women with a history of affective disorder reported more psychic and somatic distress than women with no psychiatric history. Onset of a psychiatric disorder did not occur during pregnancy in this sample, and only one woman, with both a personal and family history of affective disorder, met criteria for a new episode postpartum. Brief periods of symptom elevation occurred postpartum for 14.7% of the sample (five women, two with and three without a personal history of affective disorder) in the context of additional life stressors combining with the stress of new motherhood. These findings suggest that the impact of childbearing alone on psychiatric symptoms and morbidity is modest among women who are psychiatrically healthy at pregnancy onset and have sound social support networks.

Cortisol levels in saliva and mood changes in early puerperium

Cortisol levels in saliva were measured in 22 women, daily from the 2nd to 7th day after they had given birth and in 7 control women for 6 consecutive days. During the same period the mothers filled out a mood self-rating scale. The cortisol levels of the mothers were higher than those of the controls and progressively decreased after birth except for the 4th day post-partum when there was an increase. Five mothers had post-partum blues, but their cortisol levels were not different from those of other mothers. However, there was a significant correlation between cortisol level and the mood of mothers who bottle fed their babies.

A multidisciplinary treatment approach to postpartum psychoses

Psychosis after childbirth occurs as a result of unique developmental and social demands. The authors have developed a treatment approach for the management of postpartum psychotic mothers admitted with their babies, based on their experience on an acute psychiatric inpatient unit with a special interest in the treatment of postpartum disorders. Five phases of the acute illness and recovery process are outlined. For each phase, a typical clinical situation, the specific tasks of the phase, and special problem areas are presented. The management guidelines are based on a multidisciplinary team and phase-oriented approach.