Clinical phenotypes of perinatal depression and time of symptom onset: analysis of data from an international consortium

BACKGROUND

The perinatal period is a time of high risk for onset of depressive disorders and is associated with substantial morbidity and mortality, including maternal suicide. Perinatal depression comprises a heterogeneous group of clinical subtypes, and further refinement is needed to improve treatment outcomes. We sought to empirically identify and describe clinically relevant phenotypic subtypes of perinatal depression, and further characterise subtypes by time of symptom onset within pregnancy and three post-partum periods.

METHODS

Data were assembled from a subset of seven of 19 international sites in the Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium. In this analysis, the cohort was restricted to women aged 19-40 years with information about onset of depressive symptoms in the perinatal period and complete prospective data for the ten-item Edinburgh postnatal depression scale (EPDS). Principal components and common factor analysis were used to identify symptom dimensions in the EPDS. The National Institute of Mental Health research domain criteria functional constructs of negative valence and arousal were applied to the EPDS dimensions that reflect states of depressed mood, anhedonia, and anxiety. We used k-means clustering to identify subtypes of women sharing symptom patterns. Univariate and bivariate statistics were used to describe the subtypes.

FINDINGS

Data for 663 women were included in these analyses. We found evidence for three underlying dimensions measured by the EPDS: depressed mood, anxiety, and anhedonia. On the basis of these dimensions, we identified five distinct subtypes of perinatal depression: severe anxious depression, moderate anxious depression, anxious anhedonia, pure anhedonia, and resolved depression. These subtypes have clear differences in symptom quality and time of onset. Anxiety and anhedonia emerged as prominent symptom dimensions with post-partum onset and were notably severe.

INTERPRETATION

Our findings show that there might be different types and severity of perinatal depression with varying time of onset throughout pregnancy and post partum. These findings support the need for tailored treatments that improve outcomes for women with perinatal depression.

FUNDING

Janssen Research & Development.

Maternal deaths from suicide in Singapore

INTRODUCTION

Maternal mortality in Singapore, as in other developed countries, has remained low in the past decade. In the United Kingdom and Australia, maternal deaths from suicide and psychiatric causes have been the leading cause of maternal mortality, and there have therefore been comprehensive healthcare programmes to address the mental health needs of mothers.

METHODS

In this study, we looked at maternal deaths from 2000 to 2004, by linking coronial cases of female suicide in the reproductive age group 15-45 years, with the birth registration database, to identify both early and late maternal deaths.

RESULTS

There was only one identified maternal death among 589 female suicides aged 15-45 years, occurring in a teenager within the first month postpartum. There was likely also another case that was unconfirmed and unreported.

CONCLUSION

From this preliminary study, suicide and psychiatric causes are not significant causes of maternal mortality in Singapore. However, given that the epidemiology of postnatal depression statistics mirror that of the other countries, it is possible that maternal suicides have been underreported, and the load may well be higher. There is a need for a similar confidential enquiry into maternal deaths to be set up here, as is already in place in various countries, notably the United Kingdom and Australia, for the past decade.

Suicide and other causes of mortality after post-partum psychiatric admission

BACKGROUND

The risk of suicide in postnatal women is low and those suicides that occur appear to be associated with severe psychiatric illness. No previous study has specifically studied the risk of suicide following post-partum psychiatric disorder.

METHOD

We calculated standardised mortality ratios (SMRs) for suicide, unnatural deaths and deaths from natural causes for women admitted to psychiatric hospital in the first year after childbirth, using computerised cross-linkages between the Danish Psychiatric Case Register and the Danish registers of birth and causes of death for 1973-1993.

RESULTS

During the study period 1567 women were admitted to psychiatric hospital of whom 107 (6.8%) died. The SMRs (compared with 100) were 1719 (95% CI1284-2254) for suicide, 1329 (95% CI1038-1676) for all unnatural causes and 238 (95% CI167-329) for natural causes. Suicides and deaths from all unnatural causes were most likely to occur in the first year after childbirth, the SMR for suicide within one year being 7216 (95% CI 3945-12 108).

CONCLUSIONS

Although postnatal women as a whole appear to have a low rate of suicide, severe post-partum psychiatric disorder is associated with a high rate of deaths from natural and unnatural causes, particularly suicide. The risk is especially high in the first postnatal year, when the suicide risk is increased 70-fold. Close clinical supervision at this time is indicated.