Martin Kammerer

Pregnant women become insensitive to cold stress

BackgroundThe function of the hypothalamic-pituitary-adrenal (HPA) axis is known to be altered during pregnancy, but it has not been tested with a natural stressor.MethodsA group of pregnant women (n = 10) were tested towards the end of pregnancy (mean 36.8 ± 2.5 weeks gestation) and about 8 weeks postpartum (mean 7.8 ± 1.5 weeks), together with a matched control group, with a one minute cold hand stressor test. Saliva samples were collected before and 10 and 20 minutes after the test, and stored for later radioimmunoassay of cortisol.ResultsThe control group showed a highly significant response to the test. The pregnant group showed no response, and the postpartum group a variable but non significant oneConclusionsThis shows that the HPA axis becomes hypofunctional to a natural stressor at the end of pregnancy. It is suggested that one possible evolutionary function for this is to protect the fetus from the stress responses of the mother.

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.

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.

Salivary α-amylase stability, diurnal profile and lack of response to the cold hand test in young women

Salivary cortisol measurement has proved useful for the non-invasive study of the hypothalamic–pituitary–adrenocortical axis, and salivary α-amylase has been suggested as a comparable marker for the sympathetic system. Despite some studies showing an increase in salivary α-amylase after challenges that stimulate the sympathetic nervous system, questions remain about interpretation. The aims of this study were to explore the stability of salivary α-amylase, its diurnal profile, response to the cold hand test, and correlation with cortisol. Salivary α-amylase was stable following 5 days at room temperature, and five freeze-thaw cycles. Its diurnal profile was opposite to that of cortisol. There was no salivary α-amylase response to the cold hand stress test, in the morning (11am) or afternoon (3pm), unlike cortisol which showed a response in the afternoon in the same samples. There was no correlation between salivary α-amylase and cortisol at any time. In conclusion, salivary α-amylase is stable to a range of conditions. Its diurnal pattern is compatible with sympathetic stimulation. Lack of response to the cold hand test suggests that secretion of salivary alpha-amylase is controlled by mechanisms more complex than sympathetic regulation alone.

Perinatal mental health service provision in Switzerland and in the UK.

QUESTIONS UNDER STUDY The epidemiology of maternal perinatal-psychiatric disorders as well as their effect on the baby is well recognised. Increasingly well researched specialised treatment methods can reduce maternal morbidity, positively affect mother-baby bonding and empower womens confidence as a mother. Here, we aimed to compare guidelines and the structure of perinatal-psychiatric service delivery in the United Kingdom and in Switzerland from the governments perspective. METHODS Swiss cantons provided information regarding guidelines and structure of service delivery in 2000. A subsequent survey using the same questionnaire was carried out in 2007. In the UK, similar information was accessed through published reports from 2000-2012. RESULTS Guidelines for perinatal psychiatry exist in the UK, whereas in Switzerland in 2000 none of the 26 cantons had guidelines, and in 2007 only one canton did. Joint mother-baby admissions on general psychiatric wards were offered by 92% of the Swiss cantons. In the UK, pregnant women and joint mother-baby admissions are only advised onto specialised perinatal-psychiatric units. In Switzerland, in 2007, three specialised units (max. 24 beds) were in place corresponding to 1 unit per 2.5 million people, while in the UK there were 22 mother-baby units (168 beds) in 2012 (1 unit per 2.8 million). In the UK, less than 50% of trusts provided specialised perinatal-psychiatric health care. CONCLUSIONS The main difference between the UK and Switzerland was the absence of guidelines, regular assessment and plans for future development of perinatal psychiatry in Switzerland. There are still geographical differences in the provision of perinatal-psychiatric services in the UK.

The DSM IV diagnoses of melancholic and atypical depression in pregnancy.

Atypical and melancholic subtypes of depression based on the Diagnostic and Statistical Manual (DSM) IV are important concepts, especially for biological psychiatry. The aim of this study was to determine whether the symptoms used for the diagnoses of atypical and melancholic depression can distinguish these subtypes during pregnancy. A modified version of the Structured Clinical Interview for DSM IV (SCID interview) was used that allowed assessment of all DSM IV symptoms of melancholic and atypical depression with depressed and non-depressed women in pregnancy. A Swiss cohort of 449 women was interviewed. Four diagnostic groups were compared: women with melancholic, atypical or non specified depression, and those without depression. Seventeen per cent of the cohort met SCID criteria for a depressive episode of depression at least once in pregnancy, with melancholic depression 2.4%, atypical depression 4.4% and non specified depression 10.2%. Many of the symptoms used to distinguish atypical and melancholic depression did not discriminate between these groups during pregnancy. However some, such as mood reactivity, distinct quality of mood and sleep pattern, did discriminate. Differential diagnosis between melancholic and atypical depression in pregnancy needs to be based on pregnancy specific definitions. The possible therapeutic consequences and the neurobiological basis for these findings warrant further research.

Was Wöchnerinnen wünschen: Eine qualitative Studie zur häuslichen Wochenbettbetreuung nach der Spitalentlassung durch frei praktizierende Hebammen

In Switzerland, decreases in regular hospital treatment after birth are leading increasingly to mother and child being cared for at home by independent midwives. The research herein was carried out in order to understand the needs of mothers in their home once they leave the hospital and what this midwife provided care consists of. In 2008, eight women from central Switzerland were interviewed on two separate occasions after the birth of their child, and the interviews were analysed using content analysing techniques. Mothers explained that they wanted their baby and themselves to be well cared for. They needed rest and support for recuperation and wished to spend quality time with their new family. The midwifes assisted the mothers to fulfil their needs by counselling, by instructing and by giving information, but they rarely encouraged them to be together as a family. The relationship between midwife and mother turned out to be an important support. Mothers were satisfied if mutual trust was built and if the midwife perceived their needs, respected their autonomy and took the time to be with them. Midwives contribute to the basic well-being of families and support women with medical expertise and ongoing care. Furthermore families need support in general household issues so that new mothers can recover sufficiently.

Associated symptoms of depression: patterns of change during pregnancy - Letter to the editor

Dear Editor, We thank the authors of the letter for their interest in and comments on our article, BAssociated symptoms of depression: patterns of change during pregnancy.^ The aim of our paper was to examine the natural course of specific depressive symptoms throughout pregnancy in a non-clinic sample. The findings indicate that, for some symptoms, there are sizable and non-linear changes in symptom frequency across the 9month period of study. Whether or not these symptom-level changes comport with biological and social changes in pregnancy is not yet clear, but we hope that the findings may encourage further research that adopts an assessment method that is more attentive to the evident detailed changes by symptom and stage of pregnancy. In their letter, the authors offered several helpful comments; we will address these in turn. The first concerns the variation in p values in Table 2, which displays the associations between the core symptom of depressed mood and the eight additional symptoms and features of depression. We agree that close attention to the statistical significance is important, perhaps particularly where multiple tests are conducted. In that regard, and using the authors’ example of selfesteem, it would certainly be possible to consider p values adjusted for the number of tests, i.e., by each month of gestation, or .05/9. That alteration would result in modest changes in p values in the Table. We did not formally do this for two reasons. One technical reason, which we note in the text, is that this analysis is exploratory because we had no a priori expectations (as it was a novel analysis). The second and more substantive point is that the key feature of Table 2 is not the p value but the effect size. That is, what is important about Table 2 is the degree to which the target symptom covaries with depressed mood across pregnancy and may (or may not) constitute a Bcore^ feature of depression. In the Discussion and conclusion section, we note that the patterns of overlap does not easily match what is known about biological changes in pregnancy (that is especially so where quadratic patterns are detected). A second issue highlighted by the authors is the need for greater research to identify the sources and causes of depression in pregnancy. We agree with that. This paper was principally concerned with patterns over time, however, and so our analyses of etiology were limited. A further comment was about the nature of the sample. As we note in the paper, we excluded patients using psychotropic medication and/or in psychological treatment to avoid the confounds of differential effect on symptoms. No exclusions were made about symptom severity without regard to treatment exposure: women who fulfilled the SCID criteria and were not in use of psychotropic medication and/or in a psychological treatment at recruitment were included (these women composed about 4% of our sample). The authors also raise the important point about recall bias and queried if we were sufficiently attentive to that matter. We Rita T. Amiel Castro and Claudia Pinard Anderman contributed equally to this work.

EPA-1076 – Pattern of change of cognitive and somatic symptoms over the course of pregnancy

Introduction Pregnancy may cause somatic alterations and possible transformation in womens behaviour, emotions and cognition. Objective To analyse monthly somatic and cognitive changes in pregnancy. Aims To examine the pattern of cognitive (depressed mood, lack of self-esteem, guilt, lack of concentration, sensitivity to criticism, thoughts of death) and somatic (decreased energy, feelings of heavy limbs and feeling worse in the morning) symptoms throughout the 9 months of pregnancy. Methods N=374 women were interviewed once (6 weeks postnatal) using a modified version of the Structured Clinical Interview for DSM IV. Women were asked whether they had experienced each symptom at any time during pregnancy and if they said yes, the monthly symptom occurrence was assessed. Repeated measures General Linear Model analysis was used. Results There were both linear (a) and quadratic (b) significant changes over time for sensitivity to criticism (Fa=20.9(1), Fb=7.02(1), pa,b=0.00), lack of concentration (Fa=37.0(1); Fb=10.3(1); pa,b=0.00), decreased energy (Fa=13.4(1), Fb=62.6(1); pa,b=0.00) and feelings of heavy limbs(Fa=92.9(1), Fb=67.7(1) pa,b=0.00). Guilt (F=0.00(1); p=0.93) showed no change over pregnancy, lack of self-esteem (F=10.15(1); p= 0.00) showed linear significance while depressed mood (F=5.15(1); p= 0.02) showed quadratic significance. After controlling for covariates, no significant interactions between them and all symptoms were found. Conclusion Cognitive symptoms changed throughout pregnancy as much as somatic symptoms. Most symptoms showed a different pattern from depressed mood (Figure 1). Sensitivity to criticism, lack of concentration, feelings of heavy limbs and decreased energy were especially high during late pregnancy. Download : Download full-size image Figure 1 . Depression pattern through 9 months of pregnancy