Anne Buist

First-time parenthood: Influences on pre- and postnatal adjustment in fathers and mothers

The objective of the study was to examine moods and adjustment through-the transition to parenthood as an issue affecting the couple; to examine not only the postpartum but also the pregnancy experience and to explore how each partners experiences interact with those of the other. A longitudinal repeated measures design was utilized with 327 healthy couples with a first-time pregnancy who were from Melbourne, Victoria in 1995–98. Each partner was interviewed on four occasions: mid- and late pregnancy, early postpartum and 4 months postnatally. Twenty per cent of mothers and 12% of fathers were significantly distressed at mid-pregnancy (Time 1) and this persisted until the early postpartum (Time 3) phase. Young age (particularly in women), negative mood, poor relationship functioning, gender role stress (particularly performance failure regarding work and sex in males) and low social support predicted distress in mid-pregnancy (Time 1). Negative mood in partner and self, and poor relationship functioning at mid-pregnancy predicted vulnerability to postnatal distress (Time 3 and/or Time 4). The incidence of distress in couples during mid- and late pregnancy is of concern and highlights the importance of considering the total transition to parenthood, not only the onset of postnatal distress. The analyses of predictors of postnatal distress from prenatal variables suggest that a ‘contagion of distress’ may operate in some couples. The standard management provided for couples experiencing pregnancy may be inadequate for many couples. These findings suggest that it is important to consider the mood and relationship quality of both partners and to offer intervention services as early as possible to offset possible progression into postnatal depression.

Postnatal mental health of women giving birth in Australia 2002–2004: findings from the beyondblue National Postnatal Depression Program

Objectives: To describe the postnatal mental health status of women giving birth in Australia 2002–2004 at 6–8 weeks postpartum. Method: Women were recruited from 43 health services across Australia. Women completed a demographic questionnaire and an Edinburgh Postnatal Depression Scale (EPDS) in pregnancy; the latter was repeated at 6–8 weeks following childbirth. Results: A total of 12 361 postnatal women (53.8% of all postnatal women surveyed) completed questionnaires as part of a depression screening programme; 15.5% of women screened had a postnatal EPDS>9 and 7.5% of women had an EPDS>12 at 6–8 weeks following childbirth. There was significant variation between States in the percentage of women scoring as being potentially depressed. The highest percentage of women scoring EPDS>12 were in Queensland and South Australia (both 10.2%) while Western Australia had the lowest point prevalence (5.6%). Women recruited from private health services in Western Australia had a significantly lower prevalence of elevated EPDS scores than those women recruited from the public health service (EPDS >12: 3.6% vs 6.4%, p=0.026); differences in the prevalence of elevated EPDS scores were not significant between public and private in Australian Capital Territory (EPDS>12: 7.6% vs 5.8%, p=0.48), where income and education was significantly higher than other States for both groups. Conclusions: Postnatal depressive symptoms affect a significant number of women giving birth in Australia, and the point prevalence on the EPDS may be higher for women in the public sector, associated with lower incomes and educational levels. Maternity services – particularly those serving women with these risk factors – need to consider how they identify and manage the emotional health needs of women in their care. Specific State-related issues, such as availability of specialist perinatal mental health services and liaison between treating health professionals, also need to be considered.

Childhood sexual abuse, parenting and postpartum depression--a 3-year follow-up study

OBJECTIVE This study is the second and final phase of a 3-year follow-up study of women who had been admitted with a major depressive episode in the postpartum period, along with their children and partners where present. The effect of a maternal sexual abuse history on the womens well-being and child outcome compared to those women without such a history is highlighted. METHOD Forty-five of an original cohort of 56 women were seen with their child where possible, when the child was an average of 36.8 months old. Twenty-two women had no history of sexual abuse, and 23 gave a history of childhood sexual abuse. Women were assessed with respect to well-being, relationships, parenting stress and psychiatric history since recruitment. The childs behavior and cognitive development was also assessed. RESULTS Women with a history of sexual abuse rated higher depression and anxiety scores (p < .05), and had greater life stresses (p < .05). Their partners rated themselves as more comforting and their children as more disturbed (p < .05). Over time, this group had failed to improve as much as the nonabuse group on these measures. There was no difference in child cognitive scores between groups. CONCLUSIONS A history of sexual abuse in women who become depressed postpartum may have long term implications for the womans mental health, her relationship with her child, as well as the emotional development of her child. It is critical to offer women in this high-risk group supports in an attempt to minimize these difficulties and any long-term adverse effects.

Childhood abuse, postpartum depression and parenting difficulties: a literature review of associations

Objective: The aim of this paper is to obtain an understanding of the links between maternal postpartum depression, poor parenting and childhood abuse, and the subsequent development of adult psychopathology in children from these families. Method: A literature review was undertaken of studies on postpartum depression looking at parental childhood abuse, parenting and child outcomes, as well as childhood abuse and its association with adult depression and parenting difficulties. Results: Considerable overlap is noted in predisposing factors for major depression, postpartum depression, inadequate parenting and childhood abuse. Links appear to begin in early infancy, suggesting postpartum depression as a possible mechanism for intergenerational transmission of psychopathology. Conclusions: Further research is required to look at the outcome of children of women who are at high risk of chronic or recurrent depression and of difficulties parenting; the postpartum period is the optimum time for identification and intervention.

Antenatal prevention of postnatal depression

Summary Twenty three women at risk for postpartum depression were offered ten classes in pregnancy and postpartum, focusing on parenting and coping strategies. Twenty one controls attended standard six antenatal classes. Postpartum there were no differences in depression scores, however, anxiety was less at six weeks postpartum in the intervention group. Over time both groups had reduced numbers and reduced satisfaction with supports, but this was greater in the control group. With respect to the marital relationship, this was also less satisfactory postpartum in the control group. The intervention group was well attended and participants satisfied with the alternative antenatal class format; larger studies for all first time mothers are recommended.

A psychosocial risk assessment model (PRAM) for use with pregnant and postpartum women in primary care settings

Recognition of high rates of mental health morbidity and mortality that affect women during the perinatal period has prompted the development of psychosocial risk assessment programs. Designed to identify women, at risk, during routine health checks and delivered by primary care health service providers, these fit within a primary prevention and early intervention strategic approach to the reduction of perinatal mental illness and reflect an integrated approach to perinatal health services delivery. This paper describes the development and use of the psychosocial risk assessment model (PRAM) at the Royal Hospital for Women in Sydney, Australia. Data is presented on 2,142 women who attended the Antenatal Midwives Clinic between 2002 and 2005. The PRAM guides primary care staff to quickly identify women experiencing emotional distress and/or psychosocial problems during pregnancy or postnatal checks. Measures used in pregnancy are the symptom-based Edinburgh Depression Scale and the psychosocial risk-based Antenatal Risk Questionnaire. In postnatal setting the Postnatal Risk Questionnaire is used. Scores can be used to compute a Psychosocial Risk Index (PRI) to guide individualized care planning, define needs for referral and classify groups for clinical and research purposes. Based on the PRI, among 2,142 women assessed in pregnancy 70.6% were classified as low/no risk (no interventions indicated currently), 24.1% as medium risk (in need of monitoring), and 5.3% as high risk (complex). The PRAM offers a conceptual framework, methods and measures for brief psychosocial assessment with clinical and research applications. Postpartum follow up studies of women assessed during pregnancy have commenced. Randomized controlled trials and cross-cultural studies are now indicated to strengthen the evidence base for the model.

Childhood abuse, parenting and postpartum depression

Objective: While the potential negative effects on children of maternal depression has been documented, the influence of a maternal history of childhood abuse on child development is unclear. This study, the first stage of a 3–year follow-up study, looks at childhood abuse in women with depression in the postpartum period. Method: Fifty-six women admitted with postpartum depressive disorders were assessed with respect to their wellbeing, relationships and infant interaction. Twenty-eight women had a history of sexual abuse before the age of 16, nine physical/ emotional abuse and 19 had no history of abuse. Results: The mother-infant relationship was seen to be impaired in the sexually abused group (p = 0.007). The significance increased when all abused women were compared to controls (p = 0.001). In addition, abuse was associated with more severe depression on the Beck Depression Inventory (p = 0.046), and a trend to higher anxiety and longer lengths of stay (p = 0.05 for physical abuse). Partners rated themselves as being more skilled and confident parents. Conclusions: The effect of childhood abuse was indistinguishable between emotional and physical abuse in postpartum depressed women. The most significant effect was a deleterious one on the mother-infant relationship in those women with a history of abuse.

Breastfeeding and the use of psychotropic medication: a review

The advisability of continuing breastfeeding is an important issue for women with postpartum depression or psychosis. A review of the literature on psychotropic drugs in breast milk is presented. All of the major classes of psychotropic drugs (antidepressants, antipsychotics, antianxiety agents, lithium, hypnotics) have been shown to pass into breast milk following maternal ingestion. Generally, the doses to which children are exposed from breast milk, calculated from measured milk/plasma ratios, are small. Nevertheless most authors err on the side of caution and suggest that breastfeeding be avoided. There is inadequate research on the excretion of drugs into breast milk and the effects on the infant.

Mood stabilizers in pregnancy: a systematic review.

Objective: To undertake a systematic review of the effects of exposure to mood stabilizer medication in pregnancy, evaluating teratogenicity and other outcomes for mother and child. This was one of three concurrent systematic reviews of psychotropic medication exposure in pregnancy. Method: A systematic search was carried out of electronic databases, reference books and other sources for original research studies which examined the effects of commonly used mood stabilizers (sodium valproate, carbamazepine, lamotrigine and lithium carbonate) on pregnancy outcomes. These included malformations, pregnancy complications, neonatal complications and longer term developmental outcomes for children exposed. Results: All mood stabilizers were found to be associated with a risk of malformation and perinatal complications. Studies which examined longer term neurodevelopmental outcomes found poorer outcomes for those children exposed to sodium valproate or polytherapy in pregnancy than for other individual AEDs. The data available for longer term child outcomes with lithium exposure is too limited to draw any conclusions. Conclusions: This review found that exposure in pregnancy to all four commonly used mood stabilizers may be teratogenic, and is associated with increased rates of pregnancy and neonatal complications. There was also more limited information that sodium valproate may be associated with poorer longer term child developmental outcomes. These findings must be balanced with the risk of relapse and poor pregnancy and child outcomes with untreated maternal bipolar disorder. The information obtained from these reviews of psychotropic medications will assist clinicians in managing women with mental illness in pregnancy.

Serotonin discontinuation syndrome following in utero exposure to antidepressant medication: prospective controlled study

Objectives: The aim of the present study was to examine neonatal symptoms previously reported to be associated with exposure to antidepressant medication in late pregnancy in a group of infants exposed to antidepressants, using a prospective and controlled design. Method: A prospective case–control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy. Of the 27 women taking medication, 25 remained on medication in the third trimester and, of these, 23 women had complete data available. In pregnancy and after delivery women were assessed with the Beck Depression Inventory-II and a purpose-designed questionnaire. After delivery mothers were asked a set of nine questions pertaining to symptoms of discontinuation in their newborn and questions about pregnancy and delivery complications. Results: There was an increased risk of discontinuation symptoms in neonates exposed to antidepressant medication in late pregnancy and an association with higher dose medication. The study group were found to be significantly more likely to display behaviour such as crying, jitteriness, tremor, feeding, reflux and sneezing and sleep for <3 h after a feed. They also had significantly higher rates of jaundice and admissions to the special care nursery. Conclusions: Exposure to antidepressants in late pregnancy is associated with a range of symptoms in the neonate that are consistent with the effects of exposure to antidepressants in late pregnancy. The clusters of symptoms most highly correlated are the gastrointestinal and central nervous system symptoms. These finding helps to identify the common symptoms associated with a neonatal serotonin discontinuation syndrome.