Alyx Taylor

A new Mother-to-Infant Bonding Scale: links with early maternal mood

SummarySome mothers find it hard to relate to their new baby, and such failure may have long-term effects on the infant. This has been a neglected area of research. A new simple 8 item self-rating mother-to-infant bonding questionnaire has been designed to assess the feelings of a mother towards her new baby. A principal components and reliability analysis demonstrated an alpha score of 0.71. One hundred and sixty two women filled in the Kennerley Blues Scale, the Edinburgh Postnatal Depression Scale (EPDS) the Highs Scale and the new Mother to Infant Bonding Scale on day 3 postpartum. Twelve weeks later they were sent the EPDS and the Bonding scales again. One hundred and forty four returned all questionnaires. There was a strong correlation between the Bonding scores at 3 days and at 12 weeks (rs=0.54 p<0.001). Multiple regression analysis showed that those with raised Blues scores had worse, and those with raised Highs scores had better bonding at 3 days. Those with raised EPDS scores at 3 days (13 and over) had worse bonding scores in the “first few weeks” (median 4 versus 1, p = 0.028), as recalled at 12 weeks. This simple questionnaire is acceptable for use with mothers and gives significant correlations with their early mood.

Mode of delivery and subsequent stress response

We have shown that a babys stress (saliva cortisol) and crying response to inoculation at 8 weeks was related to mode of delivery, with the greatest response shown in those born by assisted delivery and the least response in those born by elective caesarean section.

The HPA axis and perinatal depression: A hypothesis.

SummaryEpisodes of depression and anxiety are as common during pregnancy as postpartum. Some start in pregnancy and resolve postpartum, others are triggered by parturition and some are maintained throughout. In order to determine any biological basis it is important to delineate these different subtypes. During pregnancy, as well as the rise in plasma oestrogen and progesterone there is a very large increase in plasma corticotropin releasing hormone (CRH), and an increase in cortisol. The latter reaches levels found in Cushing’s syndrome and major melancholic depression. Levels of all these hormones drop rapidly on parturition.We here suggest that the symptoms of antenatal and postnatal depression may be different, and linked in part with differences in the function of the hypothalamic pituitary adrenal (HPA) axis. There are two subtypes of major depression, melancholic and atypical, with some differences in symptom profile, and these subtypes are associated with opposite changes in the HPA axis. Antenatal depression may be more melancholic and associated with the raised cortisol of pregnancy, whereas postnatal depression may be more atypical, triggered by cortisol withdrawal and associated with reduced cortisol levels. There is evidence that after delivery some women experience mild bipolar II depression, and others experience post traumatic stress disorder. Both of these are associated with atypical depression. It may also be that some women are genetically predisposed to depression of the melancholic type and some to depression of the atypical type. These women may be more or less vulnerable to depression at the different stages of the perinatal period.

Diurnal pattern of cortisol output in postnatal depression

This study investigated the diurnal output of saliva cortisol in women with symptoms of depression postnatally. Twenty-one depressed and 30 non-depressed women at 7.5 weeks postpartum, and 21 non-perinatal controls, collected saliva at waking, 30 min, and 3 and 12h postwaking. Women who were not depressed postnatally showed a pattern of cortisol secretion over the day similar to non-perinatal controls. There was a significant difference in diurnal pattern between postnatally depressed and postnatally non-depressed women, due to a difference in the first two time points (waking and +30 min): compared to the other two groups who each had a significant increase in cortisol levels from waking to +30 min, the depressed women had significantly higher cortisol levels at waking and no increase at +30 min. The lack of a morning rise in the depressed women is similar to that reported for posttraumatic stress disorder and chronic fatigue syndrome and may reflect a response, in vulnerable women, to the marked cortisol withdrawal that occurs after delivery.

Increased pituitary-adrenal activation and shortened gestation in a sample of depressed pregnant women: a pilot study.

BACKGROUND Major depression (MD) is frequently accompanied by a relatively increased production of the stress hormone cortisol. During pregnancy corticotrophin releasing hormone (CRH) is secreted from the placenta and critically high levels of CRH are one of the key triggers for parturition. Maternal cortisol promotes the secretion of placental CRH. In this study, we examined the hypothesis that women suffering with MD in pregnancy would have relatively increased cortisol secretion, a time-advanced rise in placental CRH production and an earlier delivery of the baby. METHODS A group of medication-free pregnant women, free of know obstetric and medical complications, with (n=27) and without (n=38) MD were recruited. Blood concentrations of CRH, adrenocorticotrophic hormone (ACTH) and diurnal salivary cortisol concentrations were measured at fixed time points. RESULTS Maternal cortisol concentrations were highly correlated with placental CRH secretion for the entire group. Second trimester CRH concentrations and mean evening salivary cortisol concentrations were significantly higher in the depressed women. Although pregnancy length was shorter in the depressed women there were no statistical relationships between the stress hormone measures and pregnancy length. LIMITATIONS The sample size was small and highly selected. CONCLUSIONS These findings suggest that depressed pregnant women hypersecrete cortisol in a diurnal pattern similar to that typical of MD, and that this leads to a time-advanced rise in placental CRH secretion. Factors other than this stress-delivery mechanism may be contributing to the shortened pregnancy length in depressed women.

Changes in the maternal hypothalamic-pituitary-adrenal axis during the early puerperium may be related to the postpartum 'blues'.

Most women experience time‐limited and specific mood changes in the days after birth known as the maternity blues (Blues). The maternal hypothalamic‐pituitary‐adrenal (HPA) axis undergoes gradual changes during pregnancy because of an increasing production of placental corticotrophin‐releasing hormone (CRH). The abrupt withdrawal of placental CRH at birth results in a re‐equilibration of the maternal HPA axis in the days post‐delivery. These changes may be involved in the aetiology of the Blues given the central role of the HPA axis in the aetiology of mood disorders in general, and in perinatal depression in particular. We aimed to test the novel hypothesis that the experience of the Blues may be related to increased secretion of hypothalamic adrenocorticotrophic hormone (ACTH) secretagogue peptides, after the reduction in negative‐feedback inhibition on the maternal hypothalamus caused by withdrawal of placental CRH. We therefore examined hormonal changes in the HPA axis in the days after delivery in relation to daily mood changes: our specific prediction was that mood changes would parallel ACTH levels, reflecting increased hypothalamic peptide secretion. Blood concentrations of CRH, ACTH, cortisol, progesterone and oestriol were measured in 70 healthy women during the third trimester of pregnancy, and on days 1–6 post‐delivery. Blues scores were evaluated during the postpartum days. Oestriol, progesterone and CRH levels fell rapidly from pregnancy up to day 6, whereas cortisol levels fell modestly. ACTH concentrations declined from pregnancy to day 3 post‐delivery and thereafter increased up to day 6. Blues scores increased, peaking on day 5, and were positively correlated with ACTH; and negatively correlated with oestriol levels during the postpartum days, and with the reduction in CRH concentrations from pregnancy. These findings give indirect support to the hypothesis that the ‘reactivation’ of hypothalamic ACTH secretagogue peptides may be involved in the aetiology of the Blues.

Symptoms associated with the DSM IV diagnosis of depression in pregnancy and post partum

Pregnancy and the postpartum may affect symptoms of depression. However it has not yet been tested how the symptoms used for the DSM IV diagnosis of depression discriminate depressed from non depressed women perinatally. A modified version of the Structured Clinical Interview for DSM IV (SCID interview) was used that allowed assessment of all associated DSM IV symptoms of depression with depressed and non depressed women in pregnancy and the postpartum period. Loss of appetite was not associated with depression either ante or postnatally. The antenatal symptom pattern was different from the postnatal. The sensitivity of the symptoms ranged from 0.7% to 51.6%, and specificity from 61.3% to 99.1%. The best discriminating symptoms were motor retardation/agitation and concentration antenatally, and motor retardation/agitation, concentration and fatigue postnatally. Depression in pregnancy and postpartum depression show significantly different symptom profiles. Appetite is not suitable for the diagnosis of depression in the perinatal period.

An investigation into the effectiveness of traditional Chinese acupuncture (TCA) for chronic stress in adults: A randomised controlled pilot study

AIMS The aim of this exploratory, pragmatic randomised controlled trial was to investigate the effectiveness of traditional Chinese acupuncture (TCA), using an individually targeted treatment protocol delivered by a traditionally trained Chinese acupuncturist. The trial examined the treatment of chronic stress as perceived and reported by the participants, with all its diversity of presenting symptoms, rather than using a cohort approach based on a single stress-related symptom. METHODS Participants (n=18) with high self-reported stress levels were randomised into 3 groups. Group 1 received weekly TCA for 5 weeks; group 2 received weekly attention only (practitioner present and participant supine) for 5 weeks and group 3 acted as a waiting list control. The Perceived Stress Scale 14 (PSS-14) and the Measure Yourself Medical Outcome Profile (MYMOP) were completed before and after a 5-week intervention. RESULTS After 5 weeks, group 1 reported significant changes in MYMOP profile score and both MYMOP reported symptoms (p<0.05); group 2 had significant changes in MYMOP profile score and 1 symptom (p<0.05); group 3 showed no changes. The PSS-14 scores decreased in all 3 groups, but the difference between pre- and post-study within and between the groups did not reach significance in this small study. In addition, there were self-reports of improvements for group 1 for other health problems encountered during treatment. LIMITATIONS AND CONCLUSIONS The lack of clarity concerning the definition of stress makes it complex to investigate. This pilot study suggests that TCA may be successful in treating the symptoms of stress, through a combination of specific and non-specific effects; but may not relate directly to how a person perceives their stress.

Is the Diurnal Profile of Salivary Cortisol Concentration a Useful Marker for Measuring Reported Stress in Acupuncture Research? A Randomized Controlled Pilot Study

OBJECTIVES This pilot study on the use of traditional Chinese acupuncture (TCA) to treat chronic stress explored the use of the diurnal salivary cortisol profile as a potential outcome measure. DESIGN AND METHODS Adult volunteers (n=18) with high self-reported stress levels, ascertained by screening with the Perceived Stress Scale 14, were randomized into three groups. Group 1 received weekly sessions of TCA for 5 weeks; Group 2 received attention only weekly (practitioner present and subject supine) for 5 weeks, and group 3 acted as a waiting-list control. A diurnal cortisol profile was constructed for each individual at nine data points: two at baseline, five during the intervention, and two postintervention. A salivary cortisol sample was taken at four time points (on waking, 30 minutes, 3 hours, and 12 hours after waking). OUTCOME MEASURES Salivary cortisol concentrations were measured using a high-sensitivity salivary cortisol enzyme immunoassay. RESULTS The cortisol awakening response showed an average increase during the intervention for both TCA and attention groups, indicating that for these two groups the cortisol response had normalized and they were in a lower state of stress. These trends did not reach statistical significance due to individual variation and the small number of study participants. The control group showed an overall decrease in the average morning increase over the same period. No significant difference in the day decline in cortisol was found between groups at any point in the study. CONCLUSIONS This pilot study suggests that TCA could reduce stress and increase the morning rise of the cortisol profile; however, this was not distinguishable from the effect of attention only. Further work with a larger sample is necessary to provide a definitive answer regarding whether this could be sustained with more TCA treatments. The morning cortisol increase could be a useful outcome measure for monitoring the effects of treatment on perceived stress.

Urinary phenylethylamine and cortisol levels in the early puerperium

Phenylethylamine and cortisol were measured in 24-h urine samples taken from women day 2/3 postpartum, and matched controls. They also completed self-rating blues and highs scales. There was no significant difference in phenylethylamine excretion in those who scored highly with blues or highs, and either postpartum or normal controls. The number of raised values for phenylethylamine output was significantly greater in the postpartum women, who had no psychopathology, than in normal controls. Cortisol levels were significantly raised in postpartum controls compared with normal controls; women with the highs excreted significantly less cortisol than other postpartum women.