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Guintivano J, Sullivan PF, Stuebe AM, Penders T, Thorp J, Rubinow DR, Meltzer-Brody S. Adverse life events, psychiatric history, and biological predictors of postpartum depression in an ethnically diverse sample of postpartum women. Psychol Med 2018; 48:1190-1200. [PMID: 28950923 PMCID: PMC6792292 DOI: 10.1017/s0033291717002641] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Race, psychiatric history, and adverse life events have all been independently associated with postpartum depression (PPD). However, the role these play together in Black and Latina women remains inadequately studied. Therefore, we performed a case-control study of PPD, including comprehensive assessments of symptoms and biomarkers, while examining the effects of genetic ancestry. METHODS We recruited our sample (549 cases, 968 controls) at 6 weeks postpartum from obstetrical clinics in North Carolina. PPD status was determined using the MINI-plus. Psychiatric history was extracted from medical records. Participants were administered self-report instruments to assess depression (Edinburgh Postnatal Depression Scale) and adverse life events. Levels of estradiol, progesterone, brain-derived neurotrophic factor, oxytocin, and allopregnanalone were assayed. Principal components from genotype data were used to estimate genetic ancestry and logistic regression was used to identify predictors of PPD. RESULTS This population was racially diverse (68% Black, 13% Latina, 18% European). Genetic ancestry was not a predictor of PPD. Case status was predicted by a history of major depression (p = 4.01E-14), lifetime anxiety disorder diagnosis (p = 1.25E-34), and adverse life events (p = 6.06E-06). There were no significant differences between groups in any hormones or neurosteroids. CONCLUSIONS Psychiatric history and multiple exposures to adverse life events were significant predictors of PPD in a population of minority and low-income women. Genetic ancestry and hormone levels were not predictive of case status. Increased genetic vulnerability in conjunction with risk factors may predict the onset of PPD, whereas genetic ancestry does not appear predictive.
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Affiliation(s)
- J Guintivano
- Department of Psychiatry,University of North Carolina,Chapel Hill, NC,USA
| | - P F Sullivan
- Department of Psychiatry,University of North Carolina,Chapel Hill, NC,USA
| | - A M Stuebe
- Department of Obstetrics and Gynecology,University of North Carolina,NC,USA
| | - T Penders
- Department of Psychiatry and Behavioral Medicine,East Carolina University,NC,USA
| | - J Thorp
- Department of Obstetrics and Gynecology,University of North Carolina,NC,USA
| | - D R Rubinow
- Department of Psychiatry,University of North Carolina,Chapel Hill, NC,USA
| | - S Meltzer-Brody
- Department of Psychiatry,University of North Carolina,Chapel Hill, NC,USA
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Meltzer-Brody S, Larsen J, Petersen L, Guintivano J, Di Florio A, Miller W, Sullivan PF, Munk-Olsen T. Adverse life events increase risk for postpartum psychiatric episodes: A population-based epidemiologic study. Depress Anxiety 2018; 35:160-167. [PMID: 29172228 PMCID: PMC6867605 DOI: 10.1002/da.22697] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/30/2017] [Accepted: 10/08/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Trauma histories may increase risk of perinatal psychiatric episodes. We designed an epidemiological population-based cohort study to explore if adverse childhood experiences (ACE) in girls increases risk of later postpartum psychiatric episodes. METHODS Using Danish registers, we identified women born in Denmark between January 1980 and December 1998 (129,439 childbirths). Exposure variables were ACE between ages 0 and 15 including: (1) family disruption, (2) parental somatic illness, (3) parental labor market exclusion, (4) parental criminality, (5) parental death, (6) placement in out-of-home care, (7) parental psychopathology excluding substance use, and (8) parental substance use disorder. Primary outcome was first occurrence of in- or outpatient contact 0-6 months postpartum at a psychiatric treatment facility with any psychiatric diagnoses, ICD-10, F00-F99 (N = 651). We conducted survival analyses using Cox proportional hazard regressions of postpartum psychiatric episodes. RESULTS Approximately 52% of the sample experienced ACE, significantly increasing risk of any postpartum psychiatric diagnosis. Highest risks were observed among women who experienced out-of-home placement, hazard ratio (HR) 2.57 (95% CI: 1.90-3.48). Women experiencing two adverse life events had higher risks of postpartum psychiatric diagnosis HR: 1.88 (95% CI: 1.51-2.36), compared to those with one ACE, HR: 1.24 (95% CI: 1.03-49) and no ACE, HR: 1.00 (reference group). CONCLUSIONS ACE primarily due to parental psychopathology and disability contributes to increased risk of postpartum psychiatric episodes; and greater numbers of ACE increases risk for postpartum psychiatric illness with an observed dose-response effect. Future work should explore genetic and environmental factors that increase risk and/or confer resilience.
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Affiliation(s)
- S. Meltzer-Brody
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J.T. Larsen
- Department of Economics and Business Economics, The National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
| | - L. Petersen
- Department of Economics and Business Economics, The National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
| | - J. Guintivano
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A. Di Florio
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,Institute of Psychological Medicine & Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, UK
| | - W.C. Miller
- Department of Epidemiology, The Ohio State University, Columbus, OH, USA
| | - P. F. Sullivan
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - T. Munk-Olsen
- Department of Economics and Business Economics, The National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
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Meltzer-Brody S, Maegbaek ML, Medland SE, Miller WC, Sullivan P, Munk-Olsen T. Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women. Psychol Med 2017; 47:1427-1441. [PMID: 28112056 PMCID: PMC5429203 DOI: 10.1017/s0033291716003020] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Childbirth is a potent trigger for the onset of psychiatric illness in women including postpartum depression (PPD) and postpartum psychosis (PP). Medical complications occurring during pregnancy and/or childbirth have been linked to postpartum psychiatric illness and sociodemographic factors. We evaluated if pregnancy and obstetrical predictors have similar effects on different types of postpartum psychiatric disorders. METHOD A population-based cohort study using Danish registers was conducted in 392 458 primiparous women with a singleton delivery between 1995 and 2012 and no previous psychiatric history. The main outcome was first-onset postpartum psychiatric episodes. Incidence rate ratios (IRRs) were calculated for any psychiatric contact in four quarters for the first year postpartum. RESULTS PPD and postpartum acute stress reactions were associated with pregnancy and obstetrical complications. For PPD, hyperemesis gravidarum [IRR 2.69, 95% confidence interval (CI) 1.93-3.73], gestational hypertension (IRR 1.84, 95% CI 1.33-2.55), pre-eclampsia (IRR 1.45, 95% CI 1.14-1.84) and Cesarean section (C-section) (IRR 1.32, 95% CI 1.13-1.53) were associated with increased risk. For postpartum acute stress, hyperemesis gravidarum (IRR 1.93, 95% CI 1.38-2.71), preterm birth (IRR 1.51, 95% CI 1.30-1.75), gestational diabetes (IRR 1.42, 95% CI 1.03-1.97) and C-section (IRR 1.36, 95% CI 1.20-1.55) were associated with increased risk. In contrast, risk of PP was not associated with pregnancy or obstetrical complications. CONCLUSIONS Pregnancy and obstetrical complications can increase the risk for PPD and acute stress reactions but not PP. Identification of postpartum women requiring secondary care is needed to develop targeted approaches for screening and treatment. Future work should focus on understanding the contributions of psychological stressors and underlying biology on the development of postpartum psychiatric illness.
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Affiliation(s)
- S. Meltzer-Brody
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M. L. Maegbaek
- National Center for Register-based Research, Aarhus University, Aarhus, Denmark
| | - S. E. Medland
- Quantitative Genetics, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - W. C. Miller
- Department of Epidemiology, The Ohio State University, Columbus, OH, USA
| | - P. Sullivan
- Departments of Genetics and Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - T. Munk-Olsen
- National Center for Register-based Research, Aarhus University, Aarhus, Denmark
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Di Florio A, Putnam K, Altemus M, Apter G, Bergink V, Bilszta J, Brock R, Buist A, Deligiannidis KM, Devouche E, Epperson CN, Guille C, Kim D, Lichtenstein P, Magnusson PKE, Martinez P, Munk-Olsen T, Newport J, Payne J, Penninx BW, O’Hara M, Robertson-Blackmore E, Roza SJ, Sharkey KM, Stuart S, Tiemeier H, Viktorin A, Schmidt PJ, Sullivan PF, Stowe ZN, Wisner KL, Jones I, Rubinow DR, Meltzer-Brody S. The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale. Psychol Med 2017; 47:787-799. [PMID: 27866476 PMCID: PMC5369767 DOI: 10.1017/s0033291716002087] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset. METHOD Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA. RESULTS Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) 0.01), but not between European countries (∆*CFI < 0.01). CONCLUSIONS Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.
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Affiliation(s)
- A. Di Florio
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, UK
| | - K. Putnam
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M. Altemus
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - G. Apter
- Erasme Hospital, Paris Diderot University, Paris, France
| | - V. Bergink
- Department of Psychiatry/Psychology, Erasmus MC, Rotterdam, The Netherlands
- Department of Economics and Business, National Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - J. Bilszta
- Women’s Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - R. Brock
- Department of Psychological and Brain Sciences, The University of Iowa, Iowa City, IA, USA
| | - A. Buist
- Women’s Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - K. M. Deligiannidis
- Departments of Psychiatry and Obstetrics and Gynecology, Hofstra Northwell School of Medicine, Glen Oaks, NY, USA
| | - E. Devouche
- Erasme Hospital, Paris Descartes University, Paris, France
| | - C. N. Epperson
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - C. Guille
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - D. Kim
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - P. Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - P. K. E. Magnusson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - P. Martinez
- Behavioral Endocrinology Branch, National Institute of Mental Health, National Institutes of Health, Health and Human Services, Bethesda, MD, USA
| | - T. Munk-Olsen
- Department of Economics and Business, National Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - J. Newport
- Department of Psychiatry, University of Miami, Miami, FL, USA
| | - J. Payne
- Department of Psychiatry, The Johns Hopkins University, Baltimore, MD, USA
| | - B. W. Penninx
- Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - M. O’Hara
- Department of Psychological and Brain Sciences, The University of Iowa, Iowa City, IA, USA
| | | | - S. J. Roza
- Department of Psychiatry/Psychology, Erasmus MC, Rotterdam, The Netherlands
| | - K. M. Sharkey
- Department of Psychiatry, Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - S. Stuart
- Department of Psychological and Brain Sciences, The University of Iowa, Iowa City, IA, USA
| | - H. Tiemeier
- Department of Psychiatry/Psychology, Erasmus MC, Rotterdam, The Netherlands
| | - A. Viktorin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - P. J. Schmidt
- Behavioral Endocrinology Branch, National Institute of Mental Health, National Institutes of Health, Health and Human Services, Bethesda, MD, USA
| | - P. F. Sullivan
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Z. N. Stowe
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - K. L. Wisner
- Asher Center for the Study and Treatment of Depressive Disorders, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - I. Jones
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine, Cardiff, UK
| | - D. R. Rubinow
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S. Meltzer-Brody
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Munk-Olsen T, Maegbaek ML, Johannsen BM, Liu X, Howard LM, di Florio A, Bergink V, Meltzer-Brody S. Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence. Transl Psychiatry 2016; 6:e919. [PMID: 27754485 PMCID: PMC5315550 DOI: 10.1038/tp.2016.190] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/15/2016] [Accepted: 08/17/2016] [Indexed: 11/20/2022] Open
Abstract
Perinatal psychiatric episodes comprise various disorders and symptom severity, which are diagnosed and treated in multiple treatment settings. To date, no studies have quantified the incidence and prevalence of perinatal psychiatric episodes treated in primary and secondary care, which we aimed to do in the present study. We designed a descriptive prospective study and included information from Danish population registers to study first-time ever and recurrent psychiatric episodes during the perinatal period, including treatment at psychiatric facilities and general practitioners (GPs). This was done for all women who had records of one or more singleton births from 1998 until 2012. In total, we had information on 822 439 children born to 491 242 unique mothers. Results showed first-time psychiatric episodes treated at inpatient facilities were rare during pregnancy, but increased significantly shortly following childbirth (0.02 vs 0.25 per 1000 births). In comparison, first-time psychiatric episodes treated at outpatient facilities were more common, and showed little variation across pregnancy and postpartum. For every single birth resulting in postpartum episodes treated at inpatient psychiatric facilities, 2.5 births were followed by an episode treated at outpatient psychiatric facility and 12 births by GP-provided pharmacological treatment. We interpret our results the following way: treated severe and moderate psychiatric disorders have different risk patterns in relation to pregnancy and childbirth, which suggests differences in the underlying etiology. We further speculate varying treatment incidence and prevalence in pregnancy vs postpartum may indicate that the current Diagnostic and Statistical Manual of Mental Disorders-5 peripartum specifier not adequately describes at-risk periods across moderate and severe perinatal psychiatric episodes.
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Affiliation(s)
- T Munk-Olsen
- Department of Economics and Business Economics, National Center for Register-based Research, Aarhus University, Aarhus, Denmark,CIRRAU-Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark,National Center for Register-Based Research Aarhus University, Fuglesangs Allé 4, Aarhus 8210, Denmark. E-mail:
| | - M L Maegbaek
- Department of Economics and Business Economics, National Center for Register-based Research, Aarhus University, Aarhus, Denmark
| | - B M Johannsen
- Department of Economics and Business Economics, National Center for Register-based Research, Aarhus University, Aarhus, Denmark
| | - X Liu
- Department of Economics and Business Economics, National Center for Register-based Research, Aarhus University, Aarhus, Denmark
| | - L M Howard
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - A di Florio
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - V Bergink
- Department of Economics and Business Economics, National Center for Register-based Research, Aarhus University, Aarhus, Denmark,Department of Psychiatry, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - S Meltzer-Brody
- UNC Center for Women's Mood Disorder, Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kimmel MC, Lara-Cinisomo S, Melvin K, Di Florio A, Brandon A, Meltzer-Brody S. Treatment of severe perinatal mood disorders on a specialized perinatal psychiatry inpatient unit. Arch Womens Ment Health 2016; 19:645-53. [PMID: 26802019 DOI: 10.1007/s00737-016-0599-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/09/2016] [Indexed: 12/29/2022]
Abstract
Perinatal patients with bipolar and psychotic mood disorder exacerbations are challenging to treat and often receive suboptimal care. We sought to examine the treatment patterns and outcomes on one of the only US-based Perinatal Psychiatry Inpatient Units (PPIU). Perinatal patients admitted to the PPIU completed self-report measures at admission and before discharge. Retrospective chart reviews extracted history, diagnoses (current and past), and medication treatment. Patients who had discharge diagnoses of bipolar disorder, major depression with psychotic features, or postpartum psychosis were included. Forty-seven met the diagnostic inclusion criteria. Over an average length of stay (ALOS) of 9.96 days, there was significant improvement in depressive and anxiety symptoms and daily functioning (Work and Social Adjustment Scale). Psychiatric comorbidity was common. Polypharmacy was utilized in 87 %. The most common medications prescribed at discharge were antipsychotics, alone or in combination with mood stabilizers or antidepressants. ECT was performed in 10 % of cases. The complexity of patients with severe mood disorders or psychosis admitted to the PPIU supports individualized treatment plans that address both primary diagnosis and psychiatric comorbidities. Our results provide important information that can be disseminated to others to improve clinical outcomes for severe perinatal mood disorders.
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Affiliation(s)
- Mary C Kimmel
- Department of Psychiatry, University of North Carolina-Chapel Hill, Campus Box #7160, Chapel Hill, NC, 27599-7160, USA.
| | - S Lara-Cinisomo
- Department of Psychiatry, University of North Carolina-Chapel Hill, Campus Box #7160, Chapel Hill, NC, 27599-7160, USA.,University of Illinois Urbana-Champaign, Champaign, USA
| | - K Melvin
- Department of Psychiatry, University of North Carolina-Chapel Hill, Campus Box #7160, Chapel Hill, NC, 27599-7160, USA.,Cardiff University, Cardiff, UK
| | - A Di Florio
- Department of Psychiatry, University of North Carolina-Chapel Hill, Campus Box #7160, Chapel Hill, NC, 27599-7160, USA
| | - A Brandon
- Department of Psychiatry, University of North Carolina-Chapel Hill, Campus Box #7160, Chapel Hill, NC, 27599-7160, USA
| | - S Meltzer-Brody
- Department of Psychiatry, University of North Carolina-Chapel Hill, Campus Box #7160, Chapel Hill, NC, 27599-7160, USA
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Bergink V, Laursen TM, Johannsen BMW, Kushner SA, Meltzer-Brody S, Munk-Olsen T. Letter to the Editor: Postpartum psychosis and pre-eclamptic toxaemia: a reply. Psychol Med 2016; 46:2453. [PMID: 27293149 DOI: 10.1017/s0033291716001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- V Bergink
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University,Aarhus,Denmark
| | - T M Laursen
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University,Aarhus,Denmark
| | - B M W Johannsen
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University,Aarhus,Denmark
| | - S A Kushner
- Department of Psychiatry,Erasmus Medical Center,Rotterdam,The Netherlands
| | - S Meltzer-Brody
- Department of Psychiatry,The University of North Carolina at Chapel Hill,Chapel Hill,NC,USA
| | - T Munk-Olsen
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University,Aarhus,Denmark
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Zvara BJ, Meltzer-Brody S, Mills-Koonce WR, Cox M. Maternal Childhood Sexual Trauma and Early Parenting: Prenatal and Postnatal Associations. Infant Child Dev 2016; 26. [PMID: 33776590 DOI: 10.1002/icd.1991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Existing research suggests that approximately 19% of females experience childhood sexual trauma (CST). Little is known, however, about the parenting behaviour of mothers who have experienced CST. Using propensity-matched controls, the present study examines prenatal psychosocial distress, postnatal depressive symptomatology, and caregiving behaviours of women reporting CST at or before the age of 14. Data for these analyses were obtained from mother reports and from observational protocols from a longitudinal study of low-income, rural families. Propensity score methodology was used to create a contrast group matched on family of origin variables in an effort to isolate and examine the long-term associations of CST beyond the effects of other childhood adversities such as poverty. Study findings provide evidence that women with CST histories report greater prenatal psychosocial distress compared to women without trauma histories. Findings further provide evidence for a spillover process from prenatal distress to the broader caregiving system including less sensitive parenting through postnatal depressive symptoms for women with CST histories. These results highlight the importance of screening for CST and psychosocial distress and depression prenatally. Interventions for women with CST histories and directions for future study are proposed.
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Affiliation(s)
- B J Zvara
- The University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - S Meltzer-Brody
- The University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - W R Mills-Koonce
- The University of North Carolina at Greensboro, Greensboro, NC USA
| | - M Cox
- The University of North Carolina at Chapel Hill, Chapel Hill, NC USA
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Abstract
OBJECTIVE This article summarizes the literature on obstetric and gynecologic complications associated with eating disorders. METHOD We performed a comprehensive search of the current literature on obstetric and gynecologic complications associated with eating disorders using PubMed. More recent randomized-controlled trials and larger data sets received priority. We also chose those that we felt would be the most relevant to providers. RESULTS Common obstetric and gynecologic complications for women with eating disorders include infertility, unplanned pregnancy, miscarriage, poor nutrition during pregnancy, having a baby with small head circumference, postpartum depression and anxiety, sexual dysfunction and complications in the treatment for gynecologic cancers. There are also unique associations by eating disorder diagnosis, such as earlier cessation of breastfeeding in anorexia nervosa; increased polycystic ovarian syndrome in bulimia nervosa; and complications of obesity as a result of binge eating disorder. DISCUSSION We focus on possible biological and psychosocial factors underpinning risk for poor obstetric and gynecological outcomes in eating disorders. Understanding these factors may improve both our understanding of the reproductive needs of women with eating disorders and their medical outcomes. We also highlight the importance of building multidisciplinary teams to provide comprehensive care to women with eating disorders during the reproductive years.
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Affiliation(s)
- M.C. Kimmel
- Department of Psychiatry, University of North Carolina-Chapel Hill Chapel Hill, North Carolina,Correspondence to: M.C. Kimmel, Department of Psychiatry, University of North Carolina-Chapel Hill Chapel Hill, North Carolina.
| | - E.H. Ferguson
- Department of Psychiatry, University of North Carolina-Chapel Hill Chapel Hill, North Carolina
| | - S. Zerwas
- Department of Psychiatry, University of North Carolina-Chapel Hill Chapel Hill, North Carolina
| | - C.M. Bulik
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - S. Meltzer-Brody
- Department of Psychiatry, University of North Carolina-Chapel Hill Chapel Hill, North Carolina
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Bergink V, Laursen TM, Johannsen BMW, Kushner SA, Meltzer-Brody S, Munk-Olsen T. Pre-eclampsia and first-onset postpartum psychiatric episodes: a Danish population-based cohort study. Psychol Med 2015; 45:3481-3489. [PMID: 26243040 PMCID: PMC4806793 DOI: 10.1017/s0033291715001385] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent evidence suggests that postpartum psychiatric episodes may share similar etiological mechanisms with immune-related disorders. Pre-eclampsia is one of the most prevalent immune-related disorders of pregnancy. Multiple clinical features are shared between pre-eclampsia and postpartum psychiatric disorders, most prominently a strong link to first pregnancies. Therefore, we aimed to study if pre-eclampsia is a risk factor for first-onset postpartum psychiatric episodes. METHOD We conducted a cohort study using the Danish population registry, with a total of 400 717 primiparous women with a singleton delivery between 1995 and 2011. First-lifetime childbirth was the main exposure variable and the outcome of interest was first-onset postpartum psychiatric episodes. The main outcome measures were monthly incidence rate ratios (IRRs), with the period 11-12 months after birth as the reference category. Adjustments were made for age, calendar period, reproductive history, and perinatal maternal health including somatic and obstetric co-morbidity. RESULTS Primiparous women were at particularly high risk of first-onset psychiatric episodes during the first month postpartum [IRR 2.93, 95% confidence interval (CI) 2.53-3.40] and pre-eclampsia added to that risk (IRR 4.21, 95% CI 2.89-6.13). Having both pre-eclampsia and a somatic co-morbidity resulted in the highest risk of psychiatric episodes during the 3-month period after childbirth (IRR 4.81, 95% CI 2.72-8.50). CONCLUSIONS We confirmed an association between pre-eclampsia and postpartum psychiatric episodes. The possible explanations for this association, which are not mutually exclusive, include the psychological impact of a serious medical condition such as pre-eclampsia and the neurobiological impact of pre-eclampsia-related vascular pathology and inflammation.
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Affiliation(s)
- V. Bergink
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University, Fuglesangs Allé 4, Aarhus, Denmark
- Department of Psychiatry, Erasmus Medical Center, ’s Gravendijkwal 230, 3000 CA, Rotterdam, The Netherlands
| | - T. M. Laursen
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University, Fuglesangs Allé 4, Aarhus, Denmark
- CIRRAU, Centre for Integrated Register-based Research, Aarhus School of Business and Social Sciences, Aarhus University, Fuglesangs Allé 4, Aarhus, Denmark
| | - B. M. W. Johannsen
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University, Fuglesangs Allé 4, Aarhus, Denmark
| | - S. A. Kushner
- Department of Psychiatry, Erasmus Medical Center, ’s Gravendijkwal 230, 3000 CA, Rotterdam, The Netherlands
| | - S. Meltzer-Brody
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Campus Box #7160, Chapel Hill, NC 27599, USA
| | - T. Munk-Olsen
- National Center for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University, Fuglesangs Allé 4, Aarhus, Denmark
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Cox EQ, Stuebe A, Pearson B, Grewen K, Rubinow D, Meltzer-Brody S. Oxytocin and HPA stress axis reactivity in postpartum women. Psychoneuroendocrinology 2015; 55:164-72. [PMID: 25768266 PMCID: PMC4380745 DOI: 10.1016/j.psyneuen.2015.02.009] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/13/2015] [Accepted: 02/17/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Lactation is thought to buffer stress reactivity via oxytocin (OT). Dysregulation of the HPA axis has been reported in women with postpartum depression (PPD). The co-occurrence of PPD and lactation failure suggests that abnormalities in OT signaling may play a role in PPD. We hypothesized that abnormal OT signaling is implicated in dysregulated HPA axis reactivity among postpartum women with mood symptoms. In a prospective perinatal cohort, we tested associations between OT levels during breastfeeding and stress reactivity. METHODS We recruited 52 pregnant women who intended to breastfeed, among whom 47 underwent a standardized stressor, the Trier Social Stress Test (TSST), at 8 weeks postpartum. 39 were breastfeeding at time of TSST. We assessed mood symptoms using validated instruments and defined as symptomatic women with EPDS ≥ 10 and/or Spielberger ≥ 34. Following IV placement for blood draws, women breastfed their infants and then underwent the TSST. Mothers' hormone responses were quantified. RESULTS Among symptomatic breastfeeding women (N=11; asymptomatic N=28), we found lower OT levels during breastfeeding (p<0.05) and higher CORT levels (p<0.05) both during breastfeeding and the TSST, as compared to asymptomatic breastfeeding women. In a mixed effects model examining CORT reactivity by symptom group and OT AUC, we observed a paradoxical response in symptomatic breastfeeding women during the TSST (group × time × OT AUC p<0.05); higher OT AUC was associated with higher CORT. CONCLUSIONS In all breastfeeding women, the surge of OT during feeding appears to buffer subsequent stress-induced CORT secretion. However, in symptomatic breastfeeding women, we found a positive correlation between OT AUC and CORT, instead of the expected negative correlation, which we found among asymptomatic women.
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Affiliation(s)
- E Q Cox
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160, United States.
| | - A Stuebe
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160, United States
| | - B Pearson
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160, United States
| | - K Grewen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160, United States
| | - D Rubinow
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160, United States
| | - S Meltzer-Brody
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160, United States
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13
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Affiliation(s)
- S Meltzer-Brody
- Department of Psychiatry; University of North Carolina; Chapel Hill NC USA
| | - A Brandon
- Department of Psychiatry; University of North Carolina; Chapel Hill NC USA
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14
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Affiliation(s)
- S Meltzer-Brody
- University of North Carolina at Chapel Hill, Obstetrics and Gynaecology, Chapel Hill, NC 27599-7570, USA
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15
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Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ) 2005:1-8. [PMID: 15760246 PMCID: PMC4780910 DOI: 10.1037/e439372005-001] [Citation(s) in RCA: 523] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Mental health care has traditionally focused on the need to document relief of specific symptoms of a psychiatric disorder, as well as how the patient functions in social roles. Recently, there has been increased attention paid to the issue of quality of life (QOL) and psychiatric illness. There has been a growing recognition that different treatment options may vary in their effects on the patient's ability to function in multiple life domains. Studies focusing on the QOL in patients suffering from mood and anxiety disorders have become more prevalent. Depression and anxiety disorders impose a substantial cost on society in terms of both psychiatric service costs as well as the loss of the individual to society through lost work production. However, a change in the severity of depression or anxiety often correlates with a change in disability and health service utilization. Lately, there have been a number of treatment studies of anxiety and depressive disorders that have examined the effect of treatment on QOL. Although treatment may reduce the severity and frequency of target symptoms, the patient's assessment of QOL helps to differentiate a true treatment response and remission from a partial response. The evaluation of what constitutes an adequate treatment response or remission is complicated and likely requires multiple assessment instruments in order to develop a complete understanding. In both anxiety and depressive disorders, the patient suffers from impaired functioning, which results in increased healthcare utilization. Because these patients do respond to treatment, the idea of "wellness" as a high end state treatment outcome should be an important consideration when selecting a treatment option.
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Affiliation(s)
- S Meltzer-Brody
- Department of Psychiatry, Anxiety and Traumatic Stress Program, Duke University Medical Center, Durham, North Carolina 27710, USA
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Abstract
The selective serotonin reuptake inhibitors have become a first line treatment for post-traumatic stress disorder (PTSD). In a recent double-blind study in civilians, fluoxetine produced clinically and statistically significant effects on all general measures of PTSD. We examined the specific effects of fluoxetine versus placebo in the above mentioned study of PTSD clusters and individual symptoms. Individuals were included if they met criteria for PTSD according to the Structured Clinical Interview for DSM-III-R (SCID). Symptoms were assessed at sequential time points by the Structured Interview for PTSD (SIP), a clinician interview based assessment, and a self-report scale, the Davidson Trauma Scale (DTS). A total of 53 patients were included in the analysis. On the SIP and DTS, fluoxetine was found to produce statistically significant changes on all clusters. Significant effects for fluoxetine were noted on 10 items of the DTS, and 8 items of the SIP. The SIP and DTS had 6 items in common that were significant. Fluoxetine exerts a broad spectrum effect in reducing all the symptom clusters of PTSD in this sample. The symptoms of being physically upset at reminders of the trauma, avoiding thoughts of the trauma, having difficulty enjoying things, feeling distant/estranged, having a sense of foreshortened future, and impaired concentration, were the symptoms most responsive to the effects of treatment with fluoxetine on both scales.
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Affiliation(s)
- S Meltzer-Brody
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA
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18
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Abstract
The Davidson Trauma Scale (DTS) is a validated 17-item self-rating scale used in the diagnosis of post-traumatic stress disorder (PTSD), which is sensitive to the effects of treatment. It was felt that a shorter version of the scale might provide a better diagnostic screening tool. Subjects were drawn from a sample of 243 patients obtained from multiple cohorts that included a group of survivors of various forms of trauma, including natural disaster, rape and combat. All subjects had diagnostic assessments for PTSD with a clinical interview and completed the DTS. The data were randomly divided between two subsamples, and frequency and severity scores were calculated for the DTS. A four-item scale, the SPAN (named for its top four items: Startle, Physiological arousal, Anger, and Numbness), was developed. It demonstrated an efficiency of 0.88, sensitivity of 0.84, specificity of 0.91 and positive likelihood ratio of 9.1. In a replication sample, values were slightly lower but still acceptable (efficiency = 0.80). A subgroup of PTSD patients received either fluoxetine or placebo in a clinical trial, and a significant SPAN score improvement was observed on fluoxetine. The SPAN, which correlated significantly with the Impact of Events Scale, the Sheehan Disability Scale, and the Structured Interview of PTSD, was found to have a diagnostic accuracy of 88%.
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Affiliation(s)
- S Meltzer-Brody
- Department of Psychiatry, Duke University Medical Center, Anxiety and Traumatic Stress Program, Durham, NC 27710, USA
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Otto MW, Pollack MH, Sachs GS, Reiter SR, Meltzer-Brody S, Rosenbaum JF. Discontinuation of benzodiazepine treatment: efficacy of cognitive-behavioral therapy for patients with panic disorder. Am J Psychiatry 1993; 150:1485-90. [PMID: 8379551 DOI: 10.1176/ajp.150.10.1485] [Citation(s) in RCA: 164] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The primary disadvantage of high-potency benzodiazepine treatment for panic disorder is the difficulty of discontinuing the treatment. During treatment discontinuation, new symptoms may emerge and anxiety may return, preventing many patients from successfully discontinuing their treatment. In this controlled, randomized trial the authors investigated the efficacy of a cognitive-behavioral program for patients with panic disorder who were attempting to discontinue treatment with high-potency benzodiazepines. METHOD Outpatients treated for panic disorder with alprazolam or clonazepam for a minimum of 6 months and expressing a desire to stop taking the medication (N = 33) were randomly assigned to one of two taper conditions: a slow taper condition alone or a slow taper condition in conjunction with 10 weeks of group cognitive-behavioral therapy. RESULTS The rate of successful discontinuation of benzodiazepine treatment was significantly higher for the patients receiving the cognitive-behavioral program (13 of 17; 76%) than for the patients receiving the slow taper program alone (four of 16; 25%). There was no difference in the likelihood of discontinuation success between the patients treated with alprazolam and those who received clonazepam. At the 3-month follow-up evaluation, 77% of the patients in the cognitive-behavioral program who successfully discontinued benzodiazepine treatment remained benzodiazepine free. CONCLUSIONS These findings support the efficacy of cognitive-behavioral interventions in aiding benzodiazepine discontinuation for patients with panic disorder.
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Affiliation(s)
- M W Otto
- Behavior Therapy Unit, Massachusetts General Hospital, Boston 02144
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20
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Pollack MH, Otto MW, Tesar GE, Cohen LS, Meltzer-Brody S, Rosenbaum JF. Long-term outcome after acute treatment with alprazolam or clonazepam for panic disorder. J Clin Psychopharmacol 1993; 13:257-63. [PMID: 8376613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The relative effectiveness of the available treatments for panic disorder may best be understood in the context of the longitudinal course of the disorder. This study examines a number of clinically relevant issues, including long-term outcome after acute treatment, the proportion of patients remaining on single-agent treatment or requiring multiple medications or nonpharmacologic interventions over time, evidence for dose escalation during maintenance high-potency benzodiazepine therapy, and predictors of acute and long-term response to treatment. Fifty-nine panic disorder patients originally randomized to treatment in a controlled trial comparing alprazolam, clonazepam, and placebo were reevaluated in a follow-up study. At a mean follow-up of 1.5 years, 78% of patients remained on medication and the mean dosage of alprazolam and clonazepam did not increase. Our data suggest that most patients maintain benefit with long-term pharmacotherapy but that residual symptomatology may require more intensive or additional treatment strategies. Response at the endpoint of the acute trial was significantly associated with pretrial baseline Clinical Global Impression Scale score and the presence of dysthymia. Poor outcome at follow-up was associated with total duration of the disorder, agoraphobic subtype, and the presence of comorbid social phobia. We underscore the potential importance of comorbid affective and anxiety disorders as well as phobic patterns in determining long-term response to treatment.
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Affiliation(s)
- M H Pollack
- Clinical Psychopharmacology Unit, Massachusetts General Hospital, Boston 02114
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21
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Otto MW, Pollack MH, Meltzer-Brody S, Rosenbaum JF. Cognitive-behavioral therapy for benzodiazepine discontinuation in panic disorder patients. Psychopharmacol Bull 1992; 28:123-30. [PMID: 1355299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
The discontinuation of benzodiazepine treatment in patients with panic disorder may be associated with emergent withdrawal and anxiety symptoms, relapse of panic, and the inability to complete benzodiazepine taper. Although some patients may respond to slow taper strategies or the use of pharmacologic adjuncts, many continue to experience significant difficulties during benzodiazepine discontinuation. This paper presents a cognitive-behavioral conceptualization of benzodiazepine discontinuation difficulties, emphasizing "fear of fear" cycles. From this perspective the discontinuation process is seen as exposing panic disorder patients to somatic sensations associated with panic at a time when there is both increased anxiety and concern about re-emergence or worsening of panic episodes. As a consequence, patients may re-enter a cycle of catastrophic interpretations of symptoms, increased vigilance and fear, and panic. Cognitive-behavioral interventions may ameliorate discontinuation-associated difficulties and prevent the return of the panic disorder. Preliminary data supporting the efficacy of these interventions are described.
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Affiliation(s)
- M W Otto
- Behavior Therapy Unit, Massachusetts General Hospital, Boston 02114
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22
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Pollack MH, Otto MW, Rosenbaum JF, Sachs GS, O'Neil C, Asher R, Meltzer-Brody S. Longitudinal course of panic disorder: findings from the Massachusetts General Hospital Naturalistic Study. J Clin Psychiatry 1990; 51 Suppl A:12-6. [PMID: 2258371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Clinical experience and controlled studies confirm the efficacy of pharmacologic and cognitive-behavioral interventions for the acute treatment of panic disorder and agoraphobia. However, while some patients experience long periods of true remission, panic disorder remains chronic for many, with intermittent periods of acute exacerbation and continued residual distress. Findings from the Massachusetts General Hospital Naturalistic Study of the Longitudinal Course of Panic Disorder suggest that (1) a number of factors contribute to the severity and persistence of panic disorder, including phobic subtype, comorbid anxiety disorders, depression, personality disorders, and anxiety sensitivity; (2) chronicity is common; (3) for some, an anxiety diathesis is manifested early in childhood and sets the tone for later chronicity and comorbidity; (4) maladaptive personality characteristics may be manifestations of an underlying anxiety disorder; (5) patients with continued symptomatology despite improvement may benefit from the flexible integration of pharmacologic and cognitive-behavioral treatment approaches; and (6) long-term treatment is indicated for many patients.
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Affiliation(s)
- M H Pollack
- Anxiety Clinical Research Unit, Massachusetts General Hospital, Boston
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