Chutima Roomruangwong

Perinatal depression in Asian women: prevalence, associated factors, and cultural aspects

Abstract Background and Objective: Although perinatal depression is a worldwide problem, most of the studies related to this issue have been conducted in Western countries. This paper summarizes the literature on the prevalence as well as associated factors among Asian countries where the cultural attitudes, customs, and norms are considerably different from those in Western countries. Methods: We conducted a literature search using MEDLINE (PubMed) from 1968, PsychINFO from 1970, and SCOPUS database from 1982 using keywords “depression”, “antenatal”, “antepartum”, “pregnancy”, “postnatal”, “postpartum”, “perinatal”, “after childbirth” and “Asia”. Only the articles published in English were included. Results: The overall prevalence of depression during pregnancy and postnatal period are about 20% and 21.8%, respectively. The factors related to perinatal depression can be grouped into the following categories, individual characteristics, husband/marital relationship, pregnancy-related, infant-related, and other psychosocial issues. While there is considerable overlap between Asian and Western countries with respect to risk factors for perinatal depression, premarital pregnancy, conflict with mother in-law, and dissatisfaction with infant’s gender are more specific to Asian cultures. Conclusions: Studies conducted in Asian countries suggest that the prevalence of perinatal depression is slightly higher than in Western countries. There are several unique culturally related issues that clinicians treating pregnant and postpartum Asian women should be aware as they contribute to an increased risk of depression in these women.

IgA/IgM responses to tryptophan and tryptophan catabolites (TRYCATs) are differently associated with prenatal depression, physio-somatic symptoms at the end of term and premenstrual syndrome.

There is some evidence that lowered tryptophan and an activated tryptophan catabolite (TRYCAT) pathway play a role in depression, somatoform disorder, and postpartum blues. The aim of this study is to delineate the associations between the TRYCAT pathway and premenstrual syndrome (PMS) and perinatal depressive and physio-somatic symptoms. We examine the associations between end of term serum IgM and IgA responses to tryptophan and 9 TRYCATs in relation to zinc, C-reactive protein (CRP), and haptoglobin and prenatal physio-somatic (previously known as psychosomatic) symptoms (fatigue, back pain, muscle pain, dyspepsia, obstipation) and prenatal and postnatal depression and anxiety symptoms as measured using the Edinburgh Postnatal Depression Scale (EPDS), Hamilton Depression Rating Scale (HAMD), and Spielberger’s State Anxiety Inventory (STAI). We included pregnant females with (n = 24) and without depression (n = 25) and 24 non-pregnant females. There were no significant associations between the IgA/IgM responses to tryptophan and TRYCATs and prenatal and postnatal depression/anxiety symptoms, except for lowered IgA responses to anthranilic acid in prenatal depression. A large part of the variance in IgA responses to most TRYCATs was explained by PMS and haptoglobin (positively) and CRP (inversely) levels. The IgA responses to TRYCATs were significantly increased in PMS, in particular picolinic, anthranilic, xanthurenic and kynurenic acid, and 3OH-kynurenine. Variance (62.5%) in physio-somatic symptoms at the end of term was explained by PMS, previous depressions, zinc (inversely), CRP and haptoglobin (both positively), and the IgM responses to quinolinic acid (positively), anthranilic acid, and tryptophan (both negatively). The results suggest that mucosa-derived TRYCAT pathway activation is significantly associated with PMS, but not with perinatal depression/anxiety symptoms. Physio-somatic symptoms in pregnancy have an immune-inflammatory pathophysiology. Induction of the TRYCAT pathway appears to be more related to physio-somatic than to depression symptoms.

Lower Serum Zinc and Higher CRP Strongly Predict Prenatal Depression and Physio-somatic Symptoms, Which All Together Predict Postnatal Depressive Symptoms

Pregnancy and delivery are associated with activation of immune-inflammatory pathways which may prime parturients to develop postnatal depression. There are, however, few data on the associations between immune-inflammatory pathways and prenatal depression and physio-somatic symptoms. This study examined the associations between serum zinc, C-reactive protein (CRP), and haptoglobin at the end of term and prenatal physio-somatic symptoms (fatigue, back pain, muscle pain, dyspepsia, obstipation) and prenatal and postnatal depressive and anxiety symptoms as measured using the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAMD), and Spielberger’s State Anxiety Inventory (STAI). Zinc and haptoglobin were significantly lower and CRP increased at the end of term as compared with non-pregnant women. Prenatal depression was predicted by lower zinc and lifetime history of depression, anxiety, and premenstrual tension syndrome (PMS). The latter histories were also significantly and inversely related to lower zinc. The severity of prenatal EDPS, HAMD, BDI, STAI, and physio-somatic symptoms was predicted by fatigue in the first and second trimesters, a positive life history of depression, anxiety, and PMS, and lower zinc and higher CRP. Postnatal depressive symptoms are predicted by prenatal depression, physio-somatic symptoms, zinc and CRP. Prenatal depressive and physio-somatic symptoms have an immune-inflammatory pathophysiology, while postnatal depressive symptoms are highly predicted by prenatal immune activation, prenatal depression, and a lifetime history of depression and PMS. Previous episodes of depression, anxiety disorders, and PMS may prime pregnant females to develop prenatal and postnatal depressive symptoms via activated immune pathways.

Activated neuro-oxidative and neuro-nitrosative pathways at the end of term are associated with inflammation and physio-somatic and depression symptoms, while predicting outcome characteristics in mother and baby

OBJECTIVES To examine oxidative & nitrosative stress (O&NS) biomarkers at the end of term in relation to perinatal affective symptoms, neuro-immune biomarkers and pregnancy-related outcome variables. METHODS We measured plasma advanced oxidation protein products (AOPP), nitric oxide metabolites (NOx), total radical trapping antioxidant parameter (TRAP), -sulfhydryl (-SH), peroxides (LOOH) and paraoxonase (PON)1 activity in pregnant women with and without prenatal depression and non-pregnant controls. RESULTS Pregnancy is accompanied by significantly increased AOPP and NOx, and lowered TRAP, -SH and LOOH. Increased O&NS and lowered LOOH and -SH levels are associated with prenatal depressive and physio-somatic symptoms (fatigue, pain, dyspepsia, gastro-intestinal symptoms). Increased AOPP and NOx are significantly associated with lowered -SH, TRAP and zinc, and with increased haptoglobin and C-reactive protein levels. Increased O&NS and lowered TRAP and PON 1 activity, at the end of term predict mother (e.g. hyperpigmentation, labor duration, caesarian section, cord length, breast milk flow) and baby (e.g. sleep and feeding problems) outcome characteristics. CONCLUSIONS Pregnancy is accompanied by interrelated signs of O&NS, lowered antioxidant defenses and activated neuro-immune pathways. Increased O&NS at the end of term is associated with perinatal depressive and physio-somatic symptoms and may predict obstetric and behavioral complications in mother and baby.

IgA/IgM Responses to Gram-Negative Bacteria are not Associated with Perinatal Depression, but with Physio-somatic Symptoms and Activation of the Tryptophan Catabolite Pathway at the End of Term and Postnatal Anxiety

Evidence has implicated the translocation of commensal Gram-negative bacteria (Gram-B) due to leaky gut in the pathophysiology of depression and physio-somatic symptoms (e.g. fatigue, pain, irritable bowel syndrome, malaise, etc.). In addition, the leaky gut may contribute to immune-inflammatory activation and oxidative stress. This study investigated whether bacterial translocation is associated with perinatal depression and anxiety scores and with prenatal physio-somatic symptoms and immune-inflammatory biomarkers, including the tryptophan catabolite (TRYCAT) pathway. Data were collected in pregnant women at the end of term (T1) and 4-6 weeks after delivery (T2) as well as in non-pregnant controls. We examined the associations between serum IgM/IgA responses to Gram-B at the end of term and depression (Edinburgh Postnatal Depression Scale -EPDS) and anxiety (Spielbergers State Anxiety Inventory -STAI) symptoms. Levels of C-reactive protein, zinc, haptoglobin, hematocrit and IgA/IgM responses to 9 TRYCATs were also measured. No significant associations of the IgA/IgM responses to Gram-B with prenatal depression and anxiety were observed. Increased IgA/IgM responses to Gram-B predict higher levels of haptoglobin, hematocrit and TRYCATs, in particular quinolinic acid and the quinolinic acid / kynurenic acid ratio. IgA responses to Gram-B were significantly lowered in pregnant women compared to age-matched non-pregnant women, while IgM responses were significantly elevated in participants with alcohol consumption. Physio-somatic symptoms at the end of term were significantly associated with IgM responses to Klebsiella pneumonia. Postnatal anxiety was significantly predicted by IgA responses to Pseudomonas aeruginosa. In conclusion, our findings suggest that pregnancy may protect against bacterial translocation, while alcohol use may increase bacterial translocation. The results suggest that end of term mucosa-derived immune responses to Gram-B contribute to immune activation, physio-somatic symptoms at the end of term and postnatal anxiety.

Antenatal depression and hematocrit levels as predictors of postpartum depression and anxiety symptoms

The aim of this study is to delineate the risk factors of antenatal depression and its consequences, including postnatal depression, and to examine whether the hematocrit (Hct) is associated with maternal depression. The Edinburgh Postnatal Depression Scale (EPDS), Spielbergers State Anxiety Inventory (STAI), Kennerley and Gath Maternity Blues Assessment Scale (KGB), Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HAMD) were assessed at the end of term (T1) and 2-3 days (T2) and 4-6 weeks (T3) after delivery in 126 women with and without antenatal depression. The Hct was measured at T1. Antenatal depression was significantly predicted by lifetime depression and premenstrual syndrome and less education. Antenatal depression was not associated with obstetric or neonatal outcomes. Antenatal depression symptoms strongly predict depression and anxiety symptoms at T2 and T3. The EPDS, KGB, STAI and BDI, but not the HAMD, scores, were significantly lower at T3 than before. The incidence of depression significantly decreased from T1 (23.8%) to T2 (7.8%) and T3 (5.3%). T1 Hct values significantly predicted the T3 postnatal EPDS, STAI, KGB and BDI scores. Delivery significantly improves depression and anxiety symptoms. Increased Hct in the third trimester is a biomarker of postpartum depression and anxiety symptoms.

A neuro-immune, neuro-oxidative and neuro-nitrosative model of prenatal and postpartum depression

&NA; A large body of evidence indicates that major affective disorders are accompanied by activated neuro‐immune, neuro‐oxidative and neuro‐nitrosative stress (IO & NS) pathways. Postpartum depression is predicted by end of term prenatal depressive symptoms whilst a lifetime history of mood disorders appears to increase the risk for both prenatal and postpartum depression. This review provides a critical appraisal of available evidence linking IO & NS pathways to prenatal and postpartum depression. The electronic databases Google Scholar, PubMed and Scopus were sources for this narrative review focusing on keywords, including perinatal depression, (auto)immune, inflammation, oxidative, nitric oxide, nitrosative, tryptophan catabolites (TRYCATs), kynurenine, leaky gut and microbiome. Prenatal depressive symptoms are associated with exaggerated pregnancy‐specific changes in IO & NS pathways, including increased C‐reactive protein, advanced oxidation protein products and nitric oxide metabolites, lowered antioxidant levels, such as zinc, as well as lowered regulatory IgM‐mediated autoimmune responses. The latter pathways coupled with lowered levels of endogenous anti‐inflammatory compounds, including &ohgr;3 polyunsaturated fatty acids, may also underpin the pathophysiology of postpartum depression. Although increased bacterial translocation, lipid peroxidation and TRYCAT pathway activation play a role in mood disorders, similar changes do not appear to be relevant in perinatal depression. Some IO & NS biomarker characteristics of mood disorders are found in prenatal depression indicating that these pathways partly contribute to the association of a lifetime history of mood disorders and perinatal depression. However, available evidence suggests that some IO & NS pathways differ significantly between perinatal depression and mood disorders in general. This review provides a new IO & NS model of prenatal and postpartum depression. HighlightsPostpartum depression is predicted by end of term prenatal depression (PND).Activated neuro‐immune pathways are associated with PND.Neuro‐oxidative pathways and lowered antioxidant levels, as well as Neuro‐nitrosative stress pathways and increased nitric oxide, are associated with PND.Protein oxidation and lowered zinc are the most important biomarkers of PND.Lowered natural IgM‐mediated autoimmune responses in pregnancy are involved in PN.

Body image dissatisfaction in pregnant and non-pregnant females is strongly predicted by immune activation and mucosa-derived activation of the tryptophan catabolite (TRYCAT) pathway

Abstract Objectives: The aim of the present study is to delineate the associations between body image dissatisfaction in pregnant women and immune-inflammatory biomarkers, i.e., C-reactive protein (CRP), zinc and IgA/IgM responses to tryptophan and tryptophan catabolites (TRYCATs). Methods: We assessed 49 pregnant and 24 non-pregnant females and assessed Body Image Satisfaction (BIS) scores at the end of term (T1), and 2–4 days (T2) and 4–6 weeks (T3) after delivery. Subjects were divided in those with a lowered BIS score (≤ 3) versus those with a higher score. Results: Logistic regression analysis showed that a lowered T1 BIS score was predicted by CRP levels and IgA responses to tryptophan (negative) and TRYCATs (positive), perinatal depression, body mass index (BMI) and age. The sum of quinolinic acid, kynurenine, 3-OH-kynurenine and 3-OH-anthranilic acid (reflecting brain quinolinic acid contents) was the single best predictor. In addition, a large part of the variance in the T1, T2 and T3 BIS scores was explained by IgA responses to tryptophan and TRYCATs, especially quinolinic acid. Conclusions: Body image dissatisfaction is strongly associated with inflammation and mucosa-derived IDO activation independently from depression, pregnancy, BMI and age. IgA responses to peripheral TRYCATs, which determine brain quinolinic acid concentrations, also predict body image dissatisfaction.

Natural regulatory IgM-mediated autoimmune responses directed against malondialdehyde regulate oxidative and nitrosative pathways and coupled with IgM responses to nitroso adducts attenuate depressive and physiosomatic symptoms at the end of term pregnanc: Autoimmunity and perinatal depression

We aimed to delineate the effects of immunoglobulin (Ig)M‐mediated autoimmune responses directed against malondialdehyde (MDA) and nitroso (SNO) adducts on nitro‐oxidative stress and depressive and physiosomatic symptoms (DPSS) at the end of term.

Associations between severity of anxiety and clinical and biological features of major affective disorders

Patients with major affective disorders (MAFD) with comorbid anxiety show a greater functional impairment than those without anxiety. The aim of this study is to delineate the associations between severity of anxiety in MAFD, namely bipolar disorder (BD) and major depression (MDD), and MAFD characteristics and serum high-density lipoprotein (HDL)-cholesterol levels. Recruited were 82 participants with anxiety disoders and 83 without anxiety disoders, including 101 MAFD patients and 51 healthy controls. We used the Hamilton Anxiety Rating Scale (HAM-A) to measure severity of anxiety and made the diagnoses of posttraumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), panic disorder (PD), generalized anxiety disorder (GAD) and phobias. The HAM-A score is significantly predicted by higher number of depressive episodes, GAD and phobias, childhood trauma, tobacco use disorder, metabolic syndrome and lowered HDL-cholesterol. Increased HAM-A scores are, independently from severity of depression, associated with lowered quality of life, increased disabilities and suicidal ideation. Lithium treatment significantly lowers HAM-A scores. It is concluded that severity of anxiety significantly worsens the phenomenology of MAFD. Therefore, treatments of MAFD should target increased severity of anxiety and its risk factors including low HDL-cholesterol, metabolic syndrome, childhood trauma and tobacco use disorder.