Prematurity at birth and adolescent depressive disorder

Evaluation of a course for neonatal fellows on providing psychosocial support to NICU families

Objectives

Families in the Neonatal Intensive Care Unit (NICU) experience significant psychological distress. Fellowship training requires education on mental health issues. No standardized program exists. We evaluated the impact of an online course, combining research with family perspectives, on neonatology fellow knowledge and self-efficacy when emotionally supporting NICU families.

Methods

Fellows from 20 programs completed a course covering: (1) Parent Mental Health, (2) Infant Mental Health, (3) Communication, and (4) Comprehensive Mental Health (e.g., discharge, bereavement) with pre- and post-course knowledge and self-efficacy assessments.

Results

Fellows (n=91) completed the course and assessments. Pre-course knowledge was similar by year of training (1^st: 66.9%; 2^nd: 67.2%; 3^rd: 67.4%). Mean knowledge and self-efficacy improved between pre- and post-course assessments regardless of training year or prior education for knowledge (d=1.2) (67.1% vs. 79.4%) and for self-efficacy (d=1.2) (4.7 vs 5.2 on 6-point Likert scale). Fellows who gained more knowledge had higher self-efficacy scores at post-test (r = .37).

Conclusions

Current neonatal fellowship training under-educates on mental health. An online course improved fellow knowledge and self-efficacy. Our course may be an exemplar for others creating similar curricula.

Innovation

An online course enriched by patient perspectives is an effective method of disseminating education around mental health.

The critical importance of follow-up to school age: Contributions of the NICHD Neonatal Research Network

Follow-up studies are essential for understanding outcomes and informing the care of infants with high risk for medical and developmental consequences because of extreme prematurity or perinatal illness. Studies that extend to school age often identify sequelae that go unrecognized in neonatal or short-term follow-up studies. Many critical neurocognitive, behavioral, functional, and health outcomes are best assessed beginning at school age. The Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN) has performed comprehensive school age evaluations of several key trial cohorts. This manuscript summarizes the important contributions of school age follow-up studies in the NRN, both historically and in ongoing research. We describe in detail the clinical questions that have been answered by the completed studies and new questions about the outcomes of high-risk infants that must be addressed by ongoing and future studies.

Infection and higher cortisol during pregnancy and risk for depressive symptoms in adolescent offspring

Prenatal infection, particularly at mid-gestation, has been associated with various psychopathological outcomes in offspring; however, findings linking prenatal infection to offspring depression outcomes have been mixed. Previous research indicates that it may be the co-occurrence of prenatal adversities (e.g., infection and stress) that are associated with depression outcomes in offspring. Nevertheless, no study to date has investigated whether higher levels of biomarkers linked to prenatal stress (e.g., cortisol) in the presence of infection may account for these outcomes. Participants were drawn from the Child Health and Development Studies (CHDS), a prospective, longitudinal study of pregnant women and their offspring. The present study included mother-offspring dyads from the Adolescent Study, a subsample of the CHDS cohort, whose offspring were assessed in adolescence and whose mothers also provided sera to be assayed for cortisol (n = 695). Hierarchical multivariable regressions were conducted to examine whether maternal cortisol during the first and second trimesters of pregnancy interacted with maternal infection to predict increased risk for symptoms of depression in adolescent offspring. There was a significant interaction of second trimester infection and higher cortisol on offspring depression scores during adolescence, controlling for maternal education (p = 0.04). Findings suggest that higher maternal cortisol may sensitize mothers and their offspring to the disruptive influences of infection during mid-pregnancy, conferring greater risk of depressive symptomatology in offspring.

Research Review: Developmental origins of depression - a systematic review and meta-analysis

BACKGROUND

Many observational studies have found a direct association between adverse in utero, perinatal and postnatal exposures and offspring's depression. These findings are consistent with the 'developmental origins of disease hypothesis'. But no review has comprehensively summarized the roles of these exposures. This review aims to systematically scrutinize the strength of associations between individual prenatal, perinatal, and postnatal exposures and subsequent depression in offspring.

METHODS

We conducted a systematic review and meta-analysis to synthesize the literature from the EMBASE, HealthStar, PsychoInfo, and Medline databases since their inception to September 1, 2019. English language articles on population-based prospective cohort studies examining the associations between in utero, perinatal, and postnatal exposures and offspring's depression were searched. Random-effects models were used to calculate pooled estimates, and heterogeneity and sensitivity tests were conducted to explore potential confounders in the relationships of depression and early-life factors. Qualitative analysis was also conducted.

RESULTS

Sixty-four prospective cohort studies with 28 exposures studied in the relationships to offspring's depression met inclusion criteria. The meta-analysis found 12 prenatal, perinatal, and postnatal characteristics were associated with an increased risk of depression in offspring: low birth weight, premature birth, small gestational age, maternal education, socioeconomic status, having younger parents (<20 years), having older parents (≥35 years), maternal smoking, paternal smoking, maternal stress, maternal anxiety, and prenatal depression. Heterogeneity and sensitivity tests supported the findings. By and large, study characteristics had no effects on conclusions. Qualitative analyses generally supported the findings of meta-analysis and reported on additional risk factors.

CONCLUSIONS

This review provides a robust and comprehensive overview of the lasting psychopathological effects of in utero, perinatal, and postnatal exposures. The findings highlight the need for clinical and public health interventions focusing on the identified risk factors. Large prospective cohort studies are warranted to investigate the combined effects of multiple co-existing early-life exposures.

The Intergenerational Effects of Intimate Partner Violence in Pregnancy: Mediating Pathways and Implications for Prevention

Prenatal intimate partner violence (P-IPV) can have significant adverse impacts on both mother and fetus. Existing P-IPV interventions focus on the safety of the mother and on reducing revictimization; yet expanding these to address the adverse impact on the fetus has considerable potential for preventing long-term negative developmental outcomes. In this review, we draw together evidence on major pathways linking exposure to P-IPV and child outcomes, arguing that these pathways represent potential targets to improve P-IPV intervention efforts. Using a narrative review of 112 articles, we discuss candidate pathways linking P-IPV to child outcomes, as well as their implications for intervention. Articles were identified via key word searches of social science and medical databases and by inspection of reference lists of the most relevant articles, including recent reviews and meta-analyses. Articles were included if they addressed issues relevant to understanding the effects of P-IPV on child outcomes via six core pathways: maternal stress and mental illness, maternal-fetal attachment, maternal substance use, maternal nutritional intake, maternal antenatal health-care utilization, and infection. We also included articles relevant for linking these pathways to P-IPV interventions. We conclude that developing comprehensive P-IPV interventions that target immediate risk to the mother as well as long-term child outcomes via the candidate mediating pathways identified have significant potential to help reduce the global burden of P-IPV.

Fetal growth restriction mice are more likely to exhibit depression-like behaviors due to stress-induced loss of dopaminergic neurons in the VTA

Fetal growth restriction (FGR) is a severe perinatal complication that can increase risk for mental illness. To investigate the mechanism by which FGR mice develop mental illness in adulthood, we established the FGR mouse model and the FGR mice did not display obvious depression-like behaviors, but after environmental stress exposure, FGR mice were more likely to exhibit depression-like behaviors than control mice. Moreover, FGR mice had significantly fewer dopaminergic neurons in the ventral tegmental area but no difference in serotoninergic neurons in the dorsal raphe. RNA-seq analysis showed that the downregulated genes in the midbrain of FGR mice were associated with many mental diseases and were especially involved in the regulation of NMDA-selective glutamate receptor (NMDAR) activity. Furthermore, the NMDAR antagonist memantine can relieve the stress-induced depression-like behaviors of FGR mice. In summary, our findings provide a theoretical basis for future research and treatment of FGR-related depression.

Intergenerational Transmission of Depression

The study of depression in mothers in relation to transmission of risk for the development of psychopathology in their children relies on solid foundations in the understanding of psychopathology, of development, and of developmental psychopathology per se. This article begins with a description of the scope of the problem, including a summary of knowledge of how mothers’ depression is associated with outcomes in children and of moderators of those associations. The sense of scope then informs a theoretical and empirical perspective on knowledge of mechanisms in those associations, with a focus on what has been learned in the past 20 years. Throughout the article, and in conclusions at the end, are suggestions for next steps in research and practice.

Neuroendocrine Networks and Functionality

Women undergo developmental and cyclic changes in hormonal exposures that affect brain function and mental health. Some women are more vulnerable to the effects of these hormonal exposures, for reasons that remain to be determined. Evidence to date indicates that anxiety and mood disorders are the most sensitive to hormonal fluctuations in women but there is also growing evidence for a protective effect of female reproductive hormones on schizophrenia. The hormonal exposures of the menstrual cycle, pregnancy, the postpartum period, lactation, and menopause are quite different and may be associated with at least partially distinct symptom profiles.

Conceptualizing Puberty as a Window of Opportunity for Impacting Health and Well-Being Across the Life Span

We promote the perspective that puberty, a separate biological process embedded in adolescence, is a "window of opportunity" for understanding and impacting health and development. First, we include a brief overview of pubertal change. Second, we propose a critical role for puberty in shaping life span health due to its connections with early life precursors, health issues and risks emerging during puberty, and health in young adulthood and beyond. Next, we discuss the importance of puberty measures in developmental research and suggest ways to make the science of puberty an important standalone research entity, as well as an essential component of studies conducted during adolescence. Finally, we discuss measurement issues, novel theoretical models of puberty, and the necessity of adopting an interdisciplinary perspective in research on puberty and in adolescence more broadly.

Sequential risk of depression in children born prematurely: A nationwide population- based analysis

BACKGROUND

Whether children born prematurely are at a high risk of depression is still unknown. The present study examined the risk of depression in children who were born prematurely, by analyzing a national cohort in Taiwan.

METHODS

All premature births between January 1, 2000, and December 31, 2010, by using the Taiwan National Health Insurance Research Database. A total of 21,478 preterm children and 85,903 full-term children were enrolled in this study. Sex, level of urbanization of residential area, and parental occupation were considered. We included participants who received a diagnosis of depression in more than two clinical visits or were hospitalized due to depression.

RESULTS

Preterm children had a 2.75-fold higher risk of depression than full-term children (95% confidence interval [CI] = 1.58-4.79, p < 0.001). Sex was not likely to be associated with depression in this study (p = 0.95). The lowest level of urbanization significantly contributed to the risk of depression in preterm children (adjusted hazard ratio = 6.8, 95% CI = 1.63-28.46, p < 0.01). Regarding parental occupation, preterm children whose parents had blue-collar and other occupations had a 3.4- and 6.06-fold higher risk of depression, respectively, compared with other children (blue-collar occupations: 95% CI = 1.04-11.15, p < 0.05; other occupations: 95% CI = 1.71-21.49, p < 0.01).

CONCLUSIONS

Preterm children had a 2.7-fold higher risk of depression than children born full-term. Early identification, timely psychiatric care, intervention strategies, and support for their families may reduce the complications of mental illness in preterm children.

The long-term effect of maternal dietary protein restriction on 5-HT1A receptor function and behavioral responses to stress in adulthood

Maternal nutrition impacts fetal development, and may play a role in determining resilience to stress and vulnerability to stress-precipitated psychiatric disorders, such as anxiety and depression. In this study, we examined the effect of a reduction in maternal dietary protein during pregnancy on the brain neurochemistry and behavior of offspring. We focused specifically on the serotonin system, the 5-HT1A receptor and the responsivity of offspring as adults to stress. Dams were fed either a low protein diet (10% protein by weight) or isocaloric control diet (20% protein by weight). The low protein diet did not alter maternal food intake and body weight, or litter size and the average birth weight of male or female littermates. 5-HT1A receptor function, as measured by quantitative autoradiography of 8-OH-DPAT (1 μM)-stimulated [35S]GTPγS binding, was markedly reduced in hippocampus of weanling female, but not male offspring (postnatal day, PND 21) of dams fed the low protein diet. The number of serotonergic cell bodies in the rostral raphe, and 5-HT metabolism in the limbic system of weanling offspring was not altered by maternal low protein diet. The deficit in hippocampal 5-HT1A receptor function observed in weanling female offspring persisted into adulthood (PND 112), and was accompanied by an increased sensitivity to stress, specifically increased immobility during a 15-minute forced swim challenge and increased anorexia following 30-minute restraint (PND 97-100). The present work begins to uncover important future directions for understanding the early developmental origins of resilience to stress, and factors that may put individuals at greater risk for stress-related psychiatric disorders.

Benefits of skin-to-skin contact during the neonatal period: Governed by epigenetic mechanisms?

The perinatal period experiences are important for later life physiology. Prematurely born babies have been shown to benefit from close contact with their mothers, and evidence suggests that epigenetic mechanisms are involved in these early imprints. This mini review is summarizing current praxis and discusses the need for more and larger studies.

Maternal Prenatal Stress and Other Developmental Risk Factors for Adolescent Depression: Spotlight on Sex Differences

Maternal stress during pregnancy has been linked to premorbid abnormalities associated with depression (e.g., difficult temperament, cognitive deficits) in offspring. However, few studies have looked across developmental periods to examine maternal stress during pregnancy and offspring depression during adolescence and whether these associations differ by sex. The current study used data from 1711 mother-offspring dyads (offspring sex: 49.8% male) in a longitudinal birth cohort study. Maternal narratives collected during pregnancy were qualitatively coded for stress-related themes by independent raters. Latent class analysis (LCA) identified distinct subgroups of offspring based on exposure to maternal prenatal stress and other developmental factors from the prenatal, childhood, and adolescent periods that have been associated with depression and/or maternal prenatal stress. LCA identified subgroups that were compared to determine whether and to what extent they differed on adolescent depressive symptoms. LCA revealed a subgroup of "high-risk" individuals, characterized by maternal factors during pregnancy (higher ambivalence/negativity and lower positivity towards the pregnancy, higher levels of hassles, lower maternal education and higher maternal age at birth, higher pre-pregnancy BMI) and offspring developmental factors (decreased cognitive functioning during childhood and adolescence, lower perceived parental support during adolescence, and higher levels of maternal depression during adolescence). High-risk females exhibited elevated conduct symptoms and higher birth order, while high-risk males exhibited decreased internalizing symptoms and lower birth order. Both high-risk males and females reported elevated depressive symptoms during adolescence relative to their "low-risk" counterparts.

Neuroendocrine Networks and Functionality

Women undergo developmental and cyclic changes in hormonal exposures that affect brain function and mental health. Some women are more vulnerable to the effects of these hormonal exposures, for reasons that remain to be determined. Evidence to date indicates that anxiety and mood disorders are the most sensitive to hormonal fluctuations in women but there is also growing evidence for a protective effect of female reproductive hormones on schizophrenia. The hormonal exposures of the menstrual cycle, pregnancy, the postpartum period, lactation, and menopause are quite different and may be associated with at least partially distinct symptom profiles.

Early Term Deliveries and the Risk of Pediatric Obstructive Sleep Apnoea in the Offspring

BACKGROUND

Preterm delivery may affect the development of the upper airways resulting in a higher risk of obstructive sleep apnoea (OSA). We investigated whether children born at early term (37-38 6/7 weeks' gestation) are at an increased risk for childhood OSA as compared with those born later.

METHODS

In this population-based cohort analysis all singleton deliveries occurring between 1991-2013 at a single regional tertiary medical centre were included. Gestational age upon delivery was sub-divided into: early preterm (<33 6/7 weeks' gestation), late preterm (34-36 6/7), early term, full term (39-40 6/7), late term (41-41 6/7), and post term (>42 0/7). Incidence of OSA related hospitalizations of the offspring, up to the age of 18 years, was evaluated. A survival curve and a Cox model were used to assess the association.

RESULTS

During the study period 240 953 deliveries met the inclusion criteria. OSA hospitalization (n = 1320) rates decreased as gestational age increased from 1.1% in the early preterm group, 0.8% in late preterm, 0.7% at early term, 0.5% in full term, 0.4% in late term, to 0.3% in post term born children. In the Cox regression, early term delivery exhibited an increased risk for paediatric OSA (adjusted hazard ratio (HR) 1.3 95% Confidence interval (CI) 1.2, 1.5) while late and post term deliveries were associated with significantly lower OSA risk when compared with full term (HR 0.8 95% CI 0.6, 0.9 and HR 0.6 95% CI 0.4, 0.8, respectively).

CONCLUSIONS

Early term deliveries are associated with higher rates of paediatric OSA, which decrease gradually as gestational age advances.

Polyunsaturated fatty acids and recurrent mood disorders: Phenomenology, mechanisms, and clinical application

A body of evidence has implicated dietary deficiency in omega-3 polyunsaturated fatty acids (n-3 PUFA), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), in the pathophysiology and etiology of recurrent mood disorders including major depressive disorder (MDD) and bipolar disorder. Cross-national and cross-sectional evidence suggests that greater habitual intake of n-3 PUFA is associated with reduced risk for developing mood symptoms. Meta-analyses provide strong evidence that patients with mood disorders exhibit low blood n-3 PUFA levels which are associated with increased risk for the initial development of mood symptoms in response to inflammation. While the etiology of this n-3 PUFA deficit may be multifactorial, n-3 PUFA supplementation is sufficient to correct this deficit and may also have antidepressant effects. Rodent studies suggest that n-3 PUFA deficiency during perinatal development can recapitulate key neuropathological, neurochemical, and behavioral features associated with mood disorders. Clinical neuroimaging studies suggest that low n-3 PUFA biostatus is associated with abnormalities in cortical structure and function also observed in mood disorders. Collectively, these findings implicate dietary n-3 PUFA insufficiency, particularly during development, in the pathophysiology of mood dysregulation, and support implementation of routine screening for and treatment of n-3 PUFA deficiency in patients with mood disorders.

Are obstetrical complications really involved in the etiology and course of schizophrenia and mood disorders?

The impact of stressful experiences during gestation or early life, leading to increased psychiatric disorders susceptibility, is currently well described in literature, however, few data are available on the association between obstetrical complications and later development of specific diagnoses or clinical features (e.g. psychotic symptoms). Aim of the present paper was to evaluate obstetrical complications frequency in different psychiatric diagnoses and their association with clinical features. Three hundred and eighty-eight patients with a diagnosis of schizophrenia, bipolar disorder or major depressive disorder were compared in terms of clinical presentation according to the presence, type and severity of obstetrical complications. Seventeen percent of the total sample (N=65) had history of at least one obstetrical complication. Patients with a history of at least one obstetrical complication result in an earlier age of onset (F=3.93, p=0.04) and a current higher GAF score (F=6.46, p=0.01). Lewis-Murray scale score was directly correlated with GAF scores (t=2.9, p=0.004) and inversely correlated with age at onset (t=-2.77, p=0.006). Obstetrical complications are frequently registered in patients with schizophrenia or mood disorders. In our sample, they appear to have an anticipatory effect on illness onset, but they seem not to be associated with a specific psychiatric diagnosis.

Detection and treatment of omega-3 fatty acid deficiency in psychiatric practice: Rationale and implementation

A body of translational evidence has implicated dietary deficiency in long-chain omega-3 (LCn-3) fatty acids, including eicosapenaenoic acid (EPA) and docosahexaenoic acid (DHA), in the pathophysiology and potentially etiology of different psychiatric disorders. Case–control studies have consistently observed low erythrocyte (red blood cell) EPA and/or DHA levels in patients with major depressive disorder, bipolar disorder, schizophrenia, and attention deficit hyperactivity disorder. Low erythrocyte EPA + DHA biostatus can be treated with fish oil-based formulations containing preformed EPA + DHA, and extant evidence suggests that fish oil supplementation is safe and well-tolerated and may have therapeutic benefits. These and other data provide a rationale for screening for and treating LCn-3 fatty acid deficiency in patients with psychiatric illness. To this end, we have implemented a pilot program that routinely measures blood fatty acid levels in psychiatric patients entering a residential inpatient clinic. To date over 130 blood samples, primarily from patients with treatment-refractory mood or anxiety disorders, have been collected and analyzed. Our initial results indicate that the majority (75 %) of patients exhibit whole blood EPA + DHA levels at ≤4 percent of total fatty acid composition, a rate that is significantly higher than general population norms (25 %). In a sub-set of cases, corrective treatment with fish oil-based products has resulted in improvements in psychiatric symptoms without notable side effects. In view of the urgent need for improvements in conventional treatment algorithms, these preliminary findings provide important support for expanding this approach in routine psychiatric practice.

Gestational age and adolescent mental health: evidence from Hong Kong's 'Children of 1997' birth cohort

BACKGROUND

Preterm, and more recently early term, birth has been identified as a risk factor for poor health. Whether the sequelae of late preterm or early term birth extends to poor mental health and well-being in adolescence is unclear and has not been systematically assessed.

METHOD

Linear regression was used to assess the adjusted associations of gestational age (very/moderate preterm (<34 weeks, n=85), late preterm (34-36 weeks, n=305), early term (37-38 weeks, n=2228), full term (39-40 weeks, n=4018), late term (41 weeks, n=809), post-term (≥42 weeks, n=213)) with self-reported self-esteem at ∼11 years (n=6935), parent-reported Rutter score assessing the common emotional and behavioural problems at ∼7 years (n=6292) and ∼11 years (n=5596) and self-reported depressive symptoms at ∼13 years (n=5795) in a population-representative Hong Kong Chinese birth cohort 'Children of 1997' where gestational age has little social patterning.

RESULTS

Very/moderate preterm birth was associated with higher Rutter subscore for hyperactivity (ß coefficients 0.5, 95% CI 0.01 to 1.00) at ∼7 years but not at ∼11 years, adjusted for sex, age, socio-economic position, parents' age at birth, birth order and secondhand smoke exposure. Similarly adjusted, late preterm, early term, late term and post-term birth were not associated with self-esteem or depressive symptoms.

CONCLUSIONS

In a population-representative birth cohort from a non-Western-developed setting, gestational age had few associations with mental health and well-being in adolescence, whereas very preterm birth was specifically associated with hyperactivity in childhood. Inconsistencies with studies from Western settings suggest setting specific unmeasured confounding may underlie any observed associations.

Mother-Child Interactions of Preterm Toddlers

INTRODUCTION

We aimed to investigate the mother-toddler relationship in preterm toddlers.

METHODS

The sample consisted of 18 mothers and their preterm toddlers (group 1) and 20 mothers and their fullterm toddlers (group 2). Anxiety and depressive symptom levels, attachment pattern, and parental attitudes of mothers and social-emotional problems and developmental level of the toddlers were explored to assess possible confounding factors in the mother-toddler relationship. Two researchers rated the Parent Infant Relationship Global Assessment Scales (PIRGAS).

RESULTS

Both the mothers in group 1 and group 2 had similar Beck Depression Inventory (BDI) and State and Trait Anxiety Inventory (STAI) scores. However, the mothers who gave birth before 32 weeks of gestation had higher trait anxiety scores than others (46±2.4 vs. 42.3±5.4, p=0.01). The groups had similar Brief Infant Toddler Social Emotional Assessment Scale (BITSEA) problem and competency scores. The parenting style of group 1 revealed that they had higher scores on the Parenting Attitude Research Instrument (PARI) subscale 5 (excessive discipline) (39.6 vs. 32.1; p=0.02).

CONCLUSION

Mother-toddler interaction and attachment security were found to be similar in fullterm and moderately preterm healthy toddlers. Our findings suggest that not the preterm birth itself but the medical, developmental, and/or neurological consequences of prematurity may affect the mother-toddler interaction. To explore the independent effect of prematurity in mother-toddler dyadic relationship, longitudinally designed studies are warranted.

Low birth weight, preterm birth and small for gestational age association with adult depression: systematic review and meta-analysis

BACKGROUND

There is no consensus on the effects that low birth weight, premature birth and intrauterine growth have on later depression.

AIMS

To review systematically the evidence on the relationship of low birth weight, smallness for gestational age (SGA) and premature birth with adult depression.

METHOD

We searched the literature for original studies assessing the effect of low birth weight, premature birth and SGA on adult depression. Separate meta-analyses were carried out for each exposure using random and fixed effects models. We evaluated the contribution of methodological covariates to heterogeneity using meta-regression.

RESULTS

We identified 14 studies evaluating low birth weight, 9 premature birth and 4 SGA. Low birth weight increased the odds of depression (OR = 1.39, 95% CI 1.21-1.60). Premature birth and SGA were not associated with depression, but publication bias might have underestimated the effect of the former and only four studies evaluated SGA.

CONCLUSIONS

Low birth weight was associated with depression. Future studies evaluating premature birth and SGA are needed.

Sex differences in anxiety and depression clinical perspectives

Sex differences are prominent in mood and anxiety disorders and may provide a window into mechanisms of onset and maintenance of affective disturbances in both men and women. With the plethora of sex differences in brain structure, function, and stress responsivity, as well as differences in exposure to reproductive hormones, social expectations and experiences, the challenge is to understand which sex differences are relevant to affective illness. This review will focus on clinical aspects of sex differences in affective disorders including the emergence of sex differences across developmental stages and the impact of reproductive events. Biological, cultural, and experiential factors that may underlie sex differences in the phenomenology of mood and anxiety disorders are discussed.

Early risk factors for psychopathology in offspring of parents with bipolar disorder: the role of obstetric complications and maternal comorbid anxiety

OBJECTIVE

Offspring of parents with bipolar disorder (BD) are at increased risk for developing a range of psychiatric disorders. Although genetic factors clearly confer risk to offspring, environmental factors also play a role in increasing vulnerability. Such environmental factors may occur at the initial stages of development in the form of obstetric complications (OCs). The current investigation examined the relationship between OCs and the development of psychopathology in offspring at risk for BD and the influence of parental psychopathology in this relationship.

METHODS

This cross-sectional study included 206 offspring of 119 parents with BD. Probit regression analyses examined associations between: (1) OC history and offspring psychopathology; and (2) maternal lifetime comorbid anxiety diagnoses and OCs in pregnancy/delivery with their offspring. Path analyses then tested whether OCs mediate the relationship between maternal comorbid anxiety disorders and offspring lifetime psychopathology.

RESULTS

Results indicated a specific association between OCs, particularly delivery complications, and increased risk for offspring anxiety disorders. Data also showed a significant relationship between maternal anxiety disorder comorbidity and OCs. Finally, path analyses suggested that delivery complications act as a mediator in the relationship between comorbid maternal anxiety disorder and offspring anxiety disorder.

CONCLUSIONS

Our findings lend support to the importance of identifying and reducing anxiety in pregnant woman with BD. The identification of OCs as early vulnerability factors for psychopathology in offspring at familial risk may also lead to earlier detection and intervention in these offspring.

Body size at birth and psychiatric disorders among adolescents: a clinical study of 310 under-age inpatient adolescents in Northern Finland

BACKGROUND

Deviant birth measure is a risk factor for later somatic illness but also for later psychiatric disorders of the offspring. Only a few studies have examined the association of birth measures to later psychiatric disorders among adolescents. Studies on sex differences in these associations are scarce as well.

METHODS

The cases consisted of 508 adolescents (208 boys and 300 girls) aged 12-17 years, who were admitted to inpatient psychiatric hospitalization between 2001 and 2006. In addition, 478 healthy controls were derived from the Northern Finnish Birth Cohort 1986, born in approximately the same period and same area as the cases. Data of birth measures were collected from the National Birth Register for cases and from antenatal clinics for controls. Both cases and controls were interviewed using the Schedule for Affective Disorder and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) to assess psychiatric disorders.

RESULTS

The adolescent patients were statistically significantly shorter and had higher ponderal index at birth compared to healthy controls. In addition, the age of the mothers at adolescent's birth was significantly younger in the patients than the controls. After controlling for various covariates, a 2.4-fold increased likelihood for internalizing disorders was seen among male adolescents with high ponderal index.

CONCLUSIONS

The association of birth measures to psychiatric disorders was confirmed in our study, particularly among male adolescents suffering from internalizing disorders. Further studies in larger adolescent samples are needed to confirm our findings and clear up the association of high ponderal index to specific psychiatric disorders.

Mental Health Outcomes in US Children and Adolescents Born Prematurely or with Low Birthweight

We examined the effects of prematurity (<37 weeks of gestation) and low birthweight (<2500 g) on mental health outcomes among US children aged 2-17 years. The 2011-2012 National Survey of Children's Health (N = 95,677) was used to estimate prevalence of parent-reported mental health problems in children. Prevalence of mental disorders was 22.9% among children born prematurely, 28.7% among very-low-birth-weight (<1500 g) children, and 18.9% among moderately low-birth-weight (1500-2499 g) children, compared with 15.5% in the general child population. Compared to those born full term, children born prematurely had 61% higher adjusted odds of serious emotional/behavioral problems, 33% higher odds of depression, and 58% higher odds of anxiety. Children born prematurely had 2.3 times higher odds of autism/ASD, 2.9 times higher odds of development delay, and 2.7 times higher odds of intellectual disability than term children. Very-low-birth-weight children had 3.2 times higher odds of autism/ASD, 1.7 times higher odds of ADD/ADHD, 5.4 times higher odds of development delay, and 4.4 times higher odds of intellectual disability than normal-birth-weight children. Social factors were significant predictors of mental disorders in both premature/low-birth-weight and term/normal-birth-weight children. Neurodevelopmental conditions accounted for the relationship between prematurity and depression/anxiety/conduct problems. Prematurity and low birthweight are significant risk factors for mental health problems among children.

Psychiatric outcomes at age seven for very preterm children: rates and predictors

BACKGROUND

  Uncertainty remains about the rate of specific psychiatric disorders and associated predictive factors for very preterm (VPT) children. The aims of this study were to document rates of psychiatric disorders in VPT children aged 7 years compared with term born children, and to examine potential predictive factors for psychiatric diagnoses in VPT children.

METHODS

  Participants were 177 VPT and 65 term born children. Perinatal medical data were collected, which included brain abnormalities detected using magnetic resonance imaging. The Infant-Toddler Social-Emotional Assessment (ITSEA) and Strengths and Difficulties Questionnaire (SDQ) were administered at 2 and 5 years respectively. At 7 years of age, the Developmental and Well-being Assessment (DAWBA) was used to indicate psychiatric diagnoses.

RESULTS

  Compared with term born children, VPT children had three times the odds of meeting criteria for any psychiatric diagnosis at age 7 years (odds ratio 3.03; 95% confidence interval 1.23, 7.47, p = .02). The most common diagnoses were anxiety disorders (11% VPT, 8% term), attention-deficit/hyperactivity disorder (10% VPT, 3% term) and autism spectrum disorder (4.5% VPT, 0% term). For VPT children, those with severe global brain abnormalities (p = .02), those who displayed social-emotional problems at age 5 (p = .000) and those with higher social risk at age 7 (p = .001) were more likely to meet criteria for a psychiatric illness at age 7.

CONCLUSIONS

Compared with term born children, VPT children have higher rates of psychiatric diagnoses at early school age, predicted by neonatal brain abnormalities, prior social-emotional problems and social factors.

The association between lower birth weight and comorbid generalised anxiety and major depressive disorder

OBJECTIVE

Studies testing the association between birth weight and depression or anxiety have found inconsistent results and there has been a lack of research on the possible relationship between birth weight and comorbid anxiety and depression. We tested for an association between lower birth weight and major depression, generalised anxiety and comorbid generalised anxiety and major depression.

METHOD

Data was taken from 2113 mothers and their offspring participating in the Mater University Study of Pregnancy (MUSP) birth cohort. Generalised anxiety, major depression and comorbid generalised anxiety and major depression at 21 years were tested for associations with birth weight using multinomial logistic regression.

RESULTS

Lower birth weight was found to predict comorbid generalised anxiety and major depression, but did not predict either generalised anxiety or major depression.

LIMITATIONS

We were unable to specify comorbidity by the primary disorder, or by the severity or recurrence of the depression.

CONCLUSION

Previous associations found between birth weight and mental health may reflect a specific link between lower birth weight and comorbid generalised anxiety and major depressive disorders. As neither disorder individually was associated with lower birth weight, this may suggest that this developmental origin represents a unique risk pathway to comorbidity not shared with either discrete disorder.

Foetal origins of depression? A systematic review and meta-analysis of low birth weight and later depression

BACKGROUND

The foetal origins hypothesis suggests an association between low birth weight and later depression, yet evidence supporting this association has been inconsistent.

METHOD

We systematically reviewed evidence for an association between low birth weight and adult depression or psychological distress in the general population by meta-analysis. We searched EMBASE, Medline, PsycINFO and ISI Web of Science for studies reporting observational data with low birth weight as the exposure and self- or clinician-rated depression or psychological distress measures as an outcome. Selective studies of exposures such as famine or outcomes such as severe illness only were excluded. Altogether,1454 studies were screened for relevance, 26 were included in the qualitative synthesis, 18 were included in the meta-analysis. A random effects meta-analysis method was used to obtain a pooled estimate of effect size.

RESULTS

The odds of depression or psychological distress was greater for those of low birth weight (<2500 g) compared to those of normal birth weight (>2500 g) or greater [odds ratio (OR) 1.15, 95% confidence intervals (CI) 1.00-1.32]. However, this association became non-significant after trim-and-fill correction for publication bias (OR 1.08, 95% CI 0.92-1.27). Using meta-regression, no differences in effect size were observed by gender, outcome measure of depression or psychological distress, or whether the effect size was adjusted for possible confounders.

CONCLUSIONS

We found evidence to support a weak association between low birth weight and later depression or psychological distress, which may be due to publication bias. It remains possible that the association may vary according to severity of symptoms or other factors.

A comparison of prematurity and small for gestational age as risk factors for age 6-13 year emotional problems

BACKGROUND

Although both very preterm (VP) and small for gestational age (SGA) births are suggested to increase the likelihood of childhood emotional problems, there has been a lack of research comparing these effects.

AIMS

To investigate levels of emotional problems between 6-13 years of age and contrast the impact of being born either very premature (irrespective of birth weight) or small for gestational age.

STUDY DESIGN

Prospective longitudinal cohort study.

SUBJECTS

654 Bavarian children (born 1985-1986) who were followed from birth to age 12/13 years.

OUTCOME MEASURES

Emotional problems at ages 6.3 and 8.5 years were measured via the Child Behavior Check List (CBCL). Emotional problems were measured at age 12/13 years via the Strengths and Difficulties Questionnaire (SDQ). Trajectories of emotional problems were derived between 6.3 and 13 years.

RESULTS

Two distinctive patterns of age 6-13 year emotional problems were found: 1) a low and stable level of problems in 76% of children; 2) a high and stable level of problems in 24% of children. The high and stable pattern of emotional problems was significantly associated with a VP but not an SGA birth. Consistent additional determinants included male child gender and lower family socioeconomic status.

CONCLUSIONS

The disparity between VP and SGA births as a predictor of age 6-13 year old emotional problems is considered in terms of fetal and/or glucocorticoid programming. The stability of emotional problems between 6 and 13 years reinforces the need for early childhood interventions aimed at children born very preterm.

Perinatal and early life factors associated with symptoms of depression in Brazilian children

Background

Few studies have been conducted on the association between perinatal and early life factors with childhood depression and results are conflicting. Our aim was to estimate the prevalence and perinatal and early life factors associated with symptoms of depression in children aged 7 to 11 years from two Brazilian birth cohorts.

Methods

The study was conducted on 1444 children whose data were collected at birth and at school age, in 1994 and 2004/2005 in Ribeirao Preto, where they were aged 10–11 years and in 1997/98 and 2005/06 in São Luís, where children were aged 7–9 years. Depressive symptoms were investigated with the Child Depression Inventory(CDI), categorized as yes (score ≥ 20) and no (score < 20). Adjusted and non-adjusted prevalence ratios (PR) were estimated by Poisson regression with robust estimation of the standard errors.

Results

The prevalence of depressive symptoms was 3.9% (95%CI = 2.5-5.4) in Ribeirão Preto and 13.7% (95%CI = 11.0-16.4) in São Luís. In the adjusted analysis, in Ribeirão Preto, low birth weight (PR = 3.98; 95%CI = 1.72-9.23), skilled and semi-skilled manual occupation (PR = 5.30; 95%CI = 1.14-24.76) and unskilled manual occupation and unemployment (PR = 6.65; 95%CI = 1.16-38.03) of the household head were risk factors for depressive symptoms. In São Luís, maternal schooling of 0–4 years (PR = 2.39; 95%CI = 1.31-4.34) and of 5 to 8 years (PR = 1.80; 95%CI = 1.08-3.01), and paternal age <20 years (PR = 1.92; 95%CI = 1.02-3.61), were independent risk factors for depressive symptoms.

Conclusions

The prevalence of depressive symptoms was much higher in the less developed city, São Luís, than in the more developed city, Ribeirão Preto, and than those reported in several international studies. Low socioeconomic level was associated with depressive symptoms in both cohorts. Low paternal age was a risk factor for depressive symptoms in the less developed city, São Luís, whereas low birth weight was a risk factor for depressive symptoms in the more developed city, Ribeirão Preto.

Birth weight, stress, and symptoms of depression in adolescence: evidence of fetal programming in a national Canadian cohort

OBJECTIVE

To investigate evidence of fetal programming in humans by studying whether adolescents born at high or low birth weights (LBW) are more likely to experience symptoms of depression and anxiety after experiencing stress.

METHOD

The sample included 3732 members of a prospective Canadian cohort study assessed for symptoms of depression and anxiety at age 12 to 15 years (2006/2007), and had birth weight and gestational age (GA) data recorded in 1994/1995. Major stressful life events and chronic stressors were also reported throughout childhood.

RESULTS

After adjusting for acute and chronic stress, being born small for GA (SGA) (OR 1.50; 95% CI 1.08 to 2.08) or large (OR 1.31; 95% CI 0.99 to 1.72) for GA was associated with an increased risk of depression and anxiety in adolescence, compared with adolescents who were born at a weight appropriate for their GA. Most interactions between birth weight and stress were not significant; however, the relation between chronic stress and adolescent depression and anxiety was more pronounced in males who were born SGA (interaction P < 0.05).

CONCLUSIONS

The link between birth weight and depression is complex and evidence of fetal programming is inconsistent; however, people born at LBW may be at an increased risk of depression in the face of chronic stress.

Hypertensive disorders in pregnancy and risk of severe mental disorders in the offspring in adulthood: the Helsinki Birth Cohort Study

BACKGROUND

Hypertensive disorders may affect the fetal developmental milieu and thus hint at mechanisms by which prenatal adversity associates with mental disorders in later life. We examined if hypertension without proteinuria and preeclampsia in pregnancy predict serious mental disorders in the offspring, and if sex, childhood socioeconomic status, length of gestation and parity modify these associations.

METHODS

We included 5970 women and men born after a normotensive, hypertensive or preeclamptic pregnancy defined by using mother's blood pressure and urinary protein measurements at maternity clinics and birth hospitals. Mental disorders requiring hospitalization or contributing to death were identified from the Finnish Hospital Discharge and Causes of Death Registers between years 1969 and 2004.

RESULTS

In comparison to the offspring born after normotensive pregnancies, offspring born after pregnancies complicated by hypertension without proteinuria were at 1.19-fold (CI: 1.01-1.41, P-value = 0.04) higher risk of any mental disorder and 1.44- (CI: 1.11-1.88, P-value < 0.01) and 1.39-fold (CI: 0.99-1.93, P-value = 0.05) higher risk of mood and anxiety disorder, respectively. In contrast, preeclampsia was associated, with a lower risk of any mental disorder in the male offspring (P-value = 0.02; P-value = 0.04 for interaction 'sex × normotension/preeclampsia').

CONCLUSIONS

Hypertension without proteinuria in pregnancy was associated with a higher risk of serious mental disorders in the offspring in adulthood. Preeclampsia seems to, in turn, associate with lower risk of severe mental disorders in male offspring.

Longitudinal predictors of psychiatric disorders in very low birth weight adults

The purpose of this study was to determine risk and protective factors for adult psychiatric disorders in very low birth weight (VLBW, birth weight <1,501 g) survivors. 79 of 154 (51%) VLBW subjects recruited at birth were assessed in early adulthood (24-27 years). Participants were screened for a psychiatric disorder; those elevated were invited to attend a structured clinical interview to determine a clinical diagnosis. Longitudinal variables measured from birth and at ages 2, 5, 14 and 18 years were included in analyses. Perinatal, developmental and social environmental risk factors failed to predict psychiatric disorder in adulthood in this cohort of VLBW survivors. Instead, low self-esteem at age 18 (odds ratio [OR] = 1.05, 95% confidence interval [CI] = 1, 1.11, p = 0.05) and the adult social environment (high rates of negative life event stress at the time of assessment: OR = 1.39, CI = 1.10, 1.76, p = 0.02), contributed significantly to adult psychiatric outcomes.

Adult psychiatric outcomes of very low birth weight survivors

BACKGROUND

Childhood studies have identified relationships between low birth weight and a variety of psychological disorders. However, very few studies have prospectively followed VLBW survivors into adulthood and none have examined adult psychiatric disorders in this population.

OBJECTIVE

This exploratory study sought to determine the rates and nature of psychiatric disorders in very low birth weight (VLBW, birth weight < 1500 g) adults.

METHOD

117 VLBW participants and 32 normal birth weight (NBW, birth weight > 2499 g) controls, born 1977-1982, were assessed in early adulthood (24-29 years). Participants were first screened for psychopathology using the Symptoms Checklist (SCL-90-R). Participants who were elevated on this measure were eligible for a Structured Clinical Interview for DSM-IV-TR (SCID-I/NP) to determine a formal psychiatric diagnosis.

RESULTS

VLBW adults were more likely than controls to be elevated on the Global Severity Index (odds ratio (OR) = 4.29, 95% confidence interval (CI) = 0.96, 19.14) and the depression (OR = 5.17, 95%CI = 1.17, 23.00), paranoid ideation (OR = 4.08, 95%CI = 0.91, 18.23), hostility (relative risk (RR) = 1.34, 95%CI = 1.21, 1.49), and interpersonal sensitivity (OR = 3.80, 95%CI = 1.08, 13.32) subscales of the SCL-90-R. VLBW adults were also more likely to be diagnosed with a current mood disorder than NBW adults (RR = 1.36, 95%CI = 1.22, 1.51).

CONCLUSIONS

VLBW adults are at greater risk of psychopathology than NBW peers.

The association between birth weight and anxiety disorders in young adults

Recent evidence has linked birth weight to later behaviour/mental disorders, yet studies have hitherto neglected to investigate the relationship between birth weight and adult anxiety disorders. Prospectively collected data from 2210 mother/offspring pairs of the Mater University Study of Pregnancy (MUSP) birth cohort was used to test for associations between birth weight z-score and four major groupings of DSM-IV anxiety disorders. Birth weight z-score was linearly and inversely associated with lifetime diagnosis of post-traumatic stress disorders at 21 years, with those falling within the smallest birth weight quintile group at almost two-fold increased odds (OR=1.96, 95% CI: 1.10, 3.52) of being diagnosed with the disorder compared to those falling within the largest group. The association remained when subsequent analysis restricted the sample to those exposed to trauma. This is the first study in which birth weight has been found to be associated with post-traumatic stress disorders in adults.

Preterm birth and childhood psychiatric disorders

Epidemiologic studies have, for many years, identified preterm birth as a significant risk factor for psychiatric disorders. There has been a recent resurgence of interest in neurobehavioral outcomes after preterm birth. In this article, we review clinical cohort studies of the prevalence, etiology, and risk factors for psychiatric sequelae in ex-preterm children. Studies using diagnostic psychiatric evaluations are few in number but typically report a 3- to 4-fold increased risk for disorders in middle childhood. Our review of studies reveals a "preterm behavioral phenotype" characterized by an increased risk for symptoms and disorders associated with inattention, anxiety, and social difficulties. The most contemporary studies have also reported a markedly increased prevalence of autism spectrum disorders (ASD) in preterm populations. Our examination of the correlates and comorbidities of psychiatric disorders is indicative of a different causative pathway that may be associated with altered brain development after preterm birth. Despite the low population attributable risk, the frequency of these symptoms and disorders means that psychiatric screening is likely to be beneficial in this vulnerable population.

Adult outcome of extremely preterm infants

Survival rates for extremely preterm (<28 weeks' gestational age) infants have increased and are approaching 3 in 4 with the advent of modern perinatal and neonatal intensive care. In contrast with some children with chronic diseases such as cystic fibrosis, most survivors of extreme prematurity have no ongoing health issues. However, as a group, they do have higher rates of adverse health outcomes, and more of them will present to pediatricians over time and, ultimately, to adult physicians as they grow older. Pediatricians can aid the transition to adult health care by being aware of the nutritional, cardiovascular, respiratory, motor, cognitive, psychiatric, and functional outcomes into adulthood of survivors of extreme prematurity.

Estimating the relative contributions of maternal genetic, paternal genetic and intrauterine factors to offspring birth weight and head circumference

BACKGROUND

Genetic factors and the prenatal environment contribute to birth weight. However, very few types of study design can disentangle their relative contribution.

AIMS

To examine maternal genetic and intrauterine contributions to offspring birth weight and head circumference. To compare the contribution of maternal and paternal genetic effects.

STUDY DESIGN

Mothers and fathers were either genetically related or unrelated to their offspring who had been conceived by in vitro fertilization.

SUBJECTS

423 singleton full term offspring, of whom 262 were conceived via homologous IVF (both parents related), 66 via sperm donation (mother only related) and 95 via egg donation (father only related).

MEASURES

Maternal weight at antenatal booking, current weight and maternal height. Paternal current weight and height were all predictors. Infant birth weight and head circumference were outcomes.

RESULTS

Genetic relatedness was the main contributing factor between measures of parental weight and offspring birth weight as correlations were only significant when the parent was related to the child. However, there was a contribution of the intrauterine environment to the association between maternal height and both infant birth weight and infant head circumference as these were significant even when mothers were unrelated to their child.

CONCLUSIONS

Both maternal and paternal genes made contributions to infant birth weight. Maternal height appeared to index a contribution of the intrauterine environment to infant growth and gestational age. Results suggested a possible biological interaction between the intrauterine environment and maternal inherited characteristics which suppresses the influence of paternal genes.

Increased depressive symptoms in female but not male adolescents born at low birth weight in the offspring of a national cohort

OBJECTIVES

To test if being born at low birth weight (LBW; <2500 g) or being small for gestational age (SGA; <10th percentile for gestational age [GA]) are associated with increased levels of depressive symptoms in youth and, if so, when these first emerge, if the relation is sex-specific, and whether this effect is direct or mediated by early life difficulties.

METHOD

Associations between LBW, SGA, and depressive symptoms at ages 4 to 7 years and 10 to 14 years were tested in 1230 children born to the female participants of the National Longitudinal Study of Youth using linear regression models adjusting for maternal age, ethnicity, education, weight, depressive symptoms, marital status, and income. We also adjusted for GA, the child's age, and depressive symptoms at ages 4 to 7 years. Attention-deficit hyperactivity disorder (ADHD) symptoms and short-term memory at ages 8 to 10 years were also assessed for their putative role in mediating this relation.

RESULTS

LBW and SGA were associated with increased levels of depressive symptoms in adolescent girls only. This persisted despite adjustment for perinatal factors and was not accounted for by putative mediators. In males and females, increased levels of depressive symptoms were associated with elevated maternal pre-pregnancy weight, depression, and single marital status, as well as childhood ADHD and depressive symptoms. Similar results were found for infants born SGA.

CONCLUSIONS

Our results support the existence of a female-specific association between LBW, SGA, and adolescent depressive symptoms. Differences in exposures to maternal mediators of stress or developmental factors may underlie these findings.

Preterm babies grown up: understanding a hidden public health problem

Even when they have grown up, the survivors of preterm birth are at increased risk of psychiatric illness. As the incidence of preterm birth is increasing, there is now a growing population of adults whose mental health needs have been neglected.

Psychiatric disorder in young adults born very preterm: Role of family history

Objective

To investigate whether young adults born very preterm (VPT) (<33 weeks) are at increased risk for psychiatric illness in adulthood and whether a family history of psychiatric disorder further increases this risk.

Methods

We assessed 169 VPT and 101 term born individuals using the Clinical Interview Schedule – Revised.

Results

Young adults born VPT had an increased risk for psychiatric disorder compared to controls (OR = 3.1, 95% CI = 1.1–8.6, p = 0.03). Those born VPT who had a history of psychiatric disorder in a first-degree relative, had an increase in risk for psychiatric disorder compared to those born VPT without a family history (OR = 5.2, 95% CI = 1.8–14.9, p = 0.002).

Conclusion

Individuals born VPT are at increased risk of psychiatric illness in young adulthood compared to controls. In addition, a family history of psychiatric disorder in a first-degree relative may leave young adults born VPT particularly vulnerable to psychiatric illness.