Anna R. Brandon

Rumination, fear, and cortisol: An in vivo study of interpersonal transgressions

The authors sought to examine whether rumination about psychologically painful, though nontraumatic, interpersonal transgressions is associated with increased salivary cortisol. They measured salivary cortisol, rumination about a transgression, fear and anger regarding the transgressor, perceived painfulness of the transgression, and positive and negative mood in 115 undergraduates who had experienced an interpersonal transgression during the previous 7 days. They obtained measurements on as many as 5 occasions separated by approximately 14 days each. On occasions when participants reported that they had been ruminating to a degree that was greater than was typical for them, they had higher levels of salivary cortisol than was typical for them. The rumination- cortisol association appeared to be mediated by fear of the transgressor. Rumination about even moderately painful but nontraumatic life events and associated emotions are related to biological changes that may subserve social goals such as avoiding social threats. Items from the rumination scale are appended.

Adolescents, Pregnancy, and Mental Health

STUDY OBJECTIVE Pregnancy during adolescence is a risk factor for adverse medical and psychosocial outcomes, including psychiatric illness. Psychiatric illness is linked with obstetric complications along with impaired maternal functioning in the postpartum period. This article provides a comprehensive review of the research examining the intersection of psychopathology and adolescent pregnancy and the postpartum period. DESIGN A literature search was conducted using PubMed (Medline), PsycINFO, and CINAHL for articles published between 1990 and 2013 that examined depression, anxiety, bipolar disorder, and psychosis during pregnancy and the postpartum period in adolescents age 21 years or younger. Articles were selected that covered the following topics: Prevalence or incidence, comorbidity, psychosocial correlates, birth outcomes, parenting, child outcomes, and psychosocial treatment. Forty articles were found and reviewed. RESULTS There is a substantial research base examining self-reported depressive symptoms in adolescents during pregnancy and the postpartum period. Existing research suggests that pregnant and parenting adolescents are at greater risk for experiencing depressive symptoms than pregnant and postpartum adult women. Depression in the perinatal period is also a risk factor for substance and alcohol abuse and a harsher parenting style in adolescents. Areas for future research in this population include investigating the prevalence, psychosocial correlates, and outcomes of clinically diagnosed Major Depressive Disorder, developing and empirically validating psychotherapeutic treatments, and focusing upon other psychiatric diagnoses such as bipolar disorder, anxiety, and psychosis.

A systematic review of the combined use of electroconvulsive therapy and psychotherapy for depression.

Objective: Electroconvulsive therapy (ECT) is one of the most effective treatments for severe major depressive disorder. However, after acute-phase treatment and initial remission, relapse rates are significant. Strategies to prolong remission include continuation phase ECT, pharmacotherapy, psychotherapy, or their combinations. This systematic review synthesizes extant data regarding the combined use of psychotherapy with ECT for the treatment of patients with severe major depressive disorder and offers the hypothesis that augmenting ECT with depression-specific psychotherapy represents a promising strategy for future investigation. Methods: The authors performed 2 independent searches in PsychInfo (1806-2009) and MEDLINE (1948-2009) using combinations of the following search terms: Electroconvulsive Therapy (including ECT, ECT therapy, electroshock therapy, EST, and shock therapy) and Psychotherapy (including cognitive behavioral, interpersonal, group, psychodynamic, psychoanalytic, individual, eclectic, and supportive). We included in this review a total of 6 articles (English language) that mentioned ECT and psychotherapy in the abstract and provided a case report, series, or clinical trial. We examined the articles for data related to ECT and psychotherapy treatment characteristics, cohort characteristics, and therapeutic outcome. Results: Although research over the past 7 decades documenting the combined use of ECT and psychotherapy is limited, the available evidence suggests that testing this combination has promise and may confer additional, positive functional outcomes. Conclusions: Significant methodological variability in ECT and psychotherapy procedures, heterogeneous patient cohorts, and inconsistent outcome measures prevent strong conclusions; however, existing research supports the need for future investigations of combined ECT and psychotherapy in well-designed, controlled clinical studies. Depression-specific psychotherapy approaches may need special adaptations in view of the cognitive effects of ECT.

Impact of Reproductive Status and Age on Response of Depressed Women to Cognitive Therapy

OBJECTIVE Previous research suggests that reproductive hormones are potential affective modulators in mood disorders and may influence response to antidepressant medications. To our knowledge, there are no data on relationships between hormonal status and response to psychotherapy for recurrent major depressive disorder (MDD). METHODS At two sites, female outpatients (n=353), aged 18-70, with recurrent MDD received 12-14 weeks of cognitive therapy (CT). Menopausal status and age were based on self-report. In the parent study, nonresponse to therapy was defined as persistence of a major depressive episode (MDE) as defined by the DSM-IV or a final Hamilton Rating Scale for Depression-17-Item (HRSD(17)) score of ≥ 12 or both. More traditional definitions of response (at least a 50% reduction in pretreatment HRSD(17)) and remission (a final HRSD(17) ≤ 6) were also examined. RESULTS Controlling for pretreatment HRSD(17) scores, there were no significant differences found in the rates of response to CT or symptom status among premenopausal, perimenopausal, and postmenopausal women. CONCLUSIONS We found no support for the hypotheses that response to CT or the rates of change in depressive symptoms are moderated by reproductive status. The findings, however, are limited by the absence of early follicular phase serum sampling/analysis to estimate hormone levels and the reliance on self-report to establish menopausal status. These data motivate a full investigation of the effects of reproductive status on response to psychosocial interventions.

Ethical Issues in Perinatal Mental Health Research

Purpose of review To review the background of current ethical standards for the conduct of perinatal mental health research and describe the ethical challenges in this research domain. Recent findings Current literature reflects a growing sentiment in the scientific community that having no information regarding the impact of psychiatric treatment on the mother and developing fetus/infant poses dangers that may exceed the risks involved in research. However, without sufficient consensus across the scientific community, both regulatory bodies and perinatal researchers find themselves without a framework for decision making that satisfactorily limits the risks and facilitates the benefits of participation of pregnant and lactating women in clinical research. Summary Psychiatric research in perinatal mental health is critically important as it enables clinicians and patients to participate in informed decision-making concerning treatment for psychiatric disorders. Specific areas of concern include fetal safety, maternal risk, the therapeutic misconception, commercial interests, forensic/legal issues, the informed consent process, and study design. Developing guidelines that address ethical challenges and include the views and concerns of multiple stakeholders could improve the access of perinatal women to the benefits of participation in mental health research in addition to providing evidence-based mental healthcare for this subpopulation.

Nonpharmacologic Treatments for Depression Related to Reproductive Events

There is a growing body of evidence suggesting that nonpharmacological interventions have an appropriate place in the treatment of major depressive disorders (MDDs) as both stand-alone and supplemental treatments. Because women may be reluctant to use psychotropic medications due to strong values or treatment preferences during specific reproductive events, clinicians need to be able to offer empirically based alternatives to medication. In this review, we present recent findings from studies of acupuncture, bright light therapy, electroconvulsive therapy, omega fatty acid supplementation, physical activity, and psychosocial intervention for women experiencing depressive symptoms in the contexts of menstruation, pregnancy, postpartum, and menopause.

When she says "no" to medication: psychotherapy for antepartum depression.

Many women suffering from major depressive disorder during pregnancy are hesitant to initiate or continue antidepressant treatment during preconception planning, conception, pregnancy, and lactation (perinatal period). Over the past few decades, various psychotherapeutic approaches have been found to be efficacious for depression in general population research. Several observational and quasi-experimental studies also suggest that psychotherapy can be a safe first-line treatment for perinatal women with mild to moderate depression. This article summarizes findings to date regarding the use of psychotherapy for depression occurring during pregnancy and describes the adaptations made to tailor the treatment to the unique needs of women in the perinatal period.

Maternal and Fetal Representations, Dimensions of Personality, and Prenatal Attachment in Women Hospitalized With High-Risk Pregnancy

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Ethical challenges in designing, conducting, and reporting research to improve the mental health of pregnant women: The voices of investigators and IRB members

Background: Legitimate concern for fetal safety often precludes women who are pregnant or planning to become pregnant from participating in randomized controlled trials (RCTs), preventing the development of an empirically-derived evidence base for the safety and efficacy of treatments. Perinatal science can only move forward when the research community understands and addresses the practical and ethical roadblocks impeding this research. Methods: To understand these challenges better, our study team interviewed 15 perinatal mental health investigators from 12 leading academic institutions in the United States and 6 members of the respective institutional review boards (IRBs). Results: Respondents confirmed seven broad ethical challenges. Through analyzing interview transcripts, we identified four themes: research design/methodology, safety, participant selection/recruitment, and autonomy. Fifteen subthemes further delineate the complexities of the issues revealed in narratives describing specific experiences related to these themes. Conclusions: The lack of reasonable solutions to these ethical challenges is a barrier to rigorous clinical research in this population, preventing the collection of empirical evidence for psychiatric care in the perinatal setting. Our study population confirms that the current federal human subjects protections guidelines (i.e., 45 CFR 46 Subpart B) do not fully address the themes of concern that emerged in the interviews. There is a need for greater flexibility in accepting womens competence to balance the risks and benefits of research participation for themselves and their fetuses.

Ethical Barriers to Perinatal Mental Health Research and Evidence-Based Treatment: An Empirical Study

Although more than 500,000 women annually experience a psychiatric illness during pregnancy, and approximately 30% will be prescribed medication, no psychotropic medications are approved by the Food and Drug Administration (FDA) for use during pregnancy. In the absence of an evidence base, investigators, clinicians, and patients are concerned that we are “operating in a vast sea of ignorance.” International pregnancy registries and observational studies exist, but there are few randomized controlled trials (RCTs), the gold standard of evidence-based medicine, due to the fear of fetal harm, even in non-pharmacological research. Current research guidelines reflect the ambivalence of regulatory agencies regarding pregnant research participants and use ambiguous language unhelpful to institutional review boards (IRBs), leaving perinatal women the last “therapeutic orphans.” This is a review of the issues as identified by perinatal investigators and a proposal to draft new collaborative guidelines to facilitate perinatal mental health research necessary for empirically-based treatment.