Michael W. O’Hara

Patient choice of treatment for postpartum depression: a pilot study.

SummaryObjective: The lack of systematic efficacy research makes the selection of optimal treatment for postpartum depression (PPD) difficult. Moreover, the treatment decisions for women with PPD who are breastfeeding are heavily influenced by their concerns about infant exposure to antidepressant medication. The objective of this pilot trial was to examine the clinical characteristics of women with PPD associated with treatment selection.Method: This open pilot trial offered 23 women with PPD one of 3 treatment options: sertraline, interpersonal psychotherapy (IPT), or their combination administered in an outpatient mental health setting over 12 weeks. Baseline and treatment outcome measures included the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI) and the Edinburgh Postnatal Depression Scale (EPDS).Results: Completers across all 3 treatment groups (n = 18) experienced significant clinical improvement with each of the 3 treatment modalities on the HRSD (p < 0.001), BDI (p < 0.001) and EPDS (p < 0.001). There were trends for women with a prior depression to more frequently choose sertraline as a treatment (alone or with IPT, p = 0.07), and for women who were breastfeeding to choose sertraline (alone or with IPT, p = 0.10) less frequently.Conclusion: In this small sample of women with PPD, most women chose IPT with or without sertraline. A larger randomized study could further confirm the suggested predictors of treatment selection identified in this study: previous depression and breastfeeding status.

Risk factors for depressive symptoms during pregnancy

The present study examined risk factors for depression during pregnancy in a very large population sample. Two research questions have been addressed: first, the association between demographic factors and past negative obstetrical outcomes on depression severity scores, and second, the differences in these factors between women recruited at a university medical center and maternal health centers (MHC). The study included more than 5,000 pregnant women attending regular appointments at the University Obstetrics and Gynecology Clinic or at several MHCs in Eastern Iowa. Participants completed a Beck depression inventory (BDI) and a demographic questionnaire. We performed a statistical analysis on the association between risk factors and depression severity scores. Regression analysis revealed that week of pregnancy, site of recruitment, years of education, income, marital status, employment, and number of miscarriages and stillbirths were significant predictors of total BDI score. Compared to their university counterparts, participants at MHCs had more depressive symptoms, were younger, mostly single, and had lower socioeconomic status and more past negative obstetrical outcomes. Our study can inform providers about some of the risk factors during depression screening in pregnancy to increase diagnostic vigilance and tailor the level of prenatal care accordingly.

The prevention and psychotherapeutic treatment of postpartum depression

Summary¶The efficacy of psychotherapeutic interventions for the acute treatment of postpartum depression is strongly supported by empirical data, which suggest that counseling is of benefit as a stand-alone treatment for postpartum depression. Given the paucity of treatment trials using medication for postpartum depression, and the fact that psychotherapeutic interventions do not confer any “exposure” risks to breastfeeding infants, the data also suggest that psychotherapy should be considered a first-line treatment, rather than as an adjunct to medication treatment. There is also some data supporting the use of psychotherapy as a means of preventing postpartum depression, though research is still needed regarding the type of interventions to be used and the types of patients towards whom the interventions should be directed.

Background and Methods

Much of the general background for the study that will be described in this monograph has been presented in chapters 1 and 2. In the first part of this chapter, the background for the specific questions that we addressed will be sketched. These include: (1) What is the prevalence of mood disorders during pregnancy and the Puerperium relative to nonchild-bearing periods? (2) In what ways do childbearing and nonchildbearing women differ psychologically when followed longitudinally? (3) What factors put women at risk for depression during pregnancy and for the blues and depression after delivery? In the second part of this chapter, the methods that we employed in this study will be outlined.

Depression and postoperative complications: an overview

BackgroundThe interaction of depression and anesthesia and surgery may result in significant increases in morbidity and mortality of patients. Major depressive disorder is a frequent complication of surgery, which may lead to further morbidity and mortality.Literature searchSeveral electronic data bases, including PubMed, were searched pairing “depression” with surgery, postoperative complications, postoperative cognitive impairment, cognition disorder, intensive care unit, mild cognitive impairment and Alzheimer’s disease.Review of the literatureThe suppression of the immune system in depressive disorders may expose the patients to increased rates of postoperative infections and increased mortality from cancer. Depression is commonly associated with cognitive impairment, which may be exacerbated postoperatively. There is evidence that acute postoperative pain causes depression and depression lowers the threshold for pain. Depression is also a strong predictor and correlate of chronic post-surgical pain. Many studies have identified depression as an independent risk factor for development of postoperative delirium, which may be a cause for a long and incomplete recovery after surgery. Depression is also frequent in intensive care unit patients and is associated with a lower health-related quality of life and increased mortality. Depression and anxiety have been widely reported soon after coronary artery bypass surgery and remain evident one year after surgery. They may increase the likelihood for new coronary artery events, further hospitalizations and increased mortality. Morbidly obese patients who undergo bariatric surgery have an increased risk of depression. Postoperative depression may also be associated with less weight loss at one year and longer. The extent of preoperative depression in patients scheduled for lumbar discectomy is a predictor of functional outcome and patient’s dissatisfaction, especially after revision surgery. General postoperative mortality is increased.ConclusionsDepression is a frequent cause of morbidity in surgery patients suffering from a wide range of conditions. Depression may be identified through the use of Patient Health Questionnaire-9 or similar instruments. Counseling interventions may be useful in ameliorating depression, but should be subject to clinical trials.

Prenatal maternal stress predicts stress reactivity at 2½ years of age: The Iowa Flood Study

Prenatal maternal stress (PNMS) predicts psychosocial development in offspring. It has been hypothesized that during PNMS, glucocorticoids pass the placenta, reaching the foetus, leading to a long-term reprogramming and dysregulation of the foetal hypothalamic-pituitary-adrenal (HPA) axis. However, results are inconsistent across PNMS studies. One problem may be the confounding of objective degrees of hardship due to the stressor and subjective degrees of distress in the mother. The present study investigated the association between objective and subjective PNMS due to a natural disaster, the June 2008 Iowa floods, and stress reactivity in the offspring at 2½ years of age. Women who were pregnant during the floods were recruited, on average, within three months of the floods and their stress levels assessed. Mothers and their toddlers (n = 94 dyads) participated in a brief mother-toddler separation to induce physiological stress responses in the offspring. Salivary cortisol samples were collected four times during the procedure. We computed absolute change in cortisol (baseline to 20-minute post-stressor; baseline to 45-minute post-stressor) and Area Under the Curve with respect to increase and ground (AUCi; AUCg). Objective and subjective PNMS were positively correlated with AUCi, as was timing in gestation: the later in pregnancy the exposure occurred, the greater the cortisol increase. Controlling for objective hardship and other covariates, sex-by-subjective PNMS interactions showed a significant and positive association between subjective PNMS and Absolute Increase (45 min) and AUCi in females only, with little effect in males. These results suggest that PNMS leads to long-term alterations in the functioning of the HPA axis, evident as early as 30-months of age.

Perceived social support interacts with prenatal depression to predict birth outcomes.

Prenatal depression has been linked to adverse reproductive outcomes including preterm labor and delivery, and low birth weight. Social support also has been linked to birth outcomes, and may buffer infants from the adverse impact of maternal depression. In this prospective study, 235 pregnant women completed questionnaires about depression and social support. Clinical interviews were administered to assess for DSM-IV axis I disorders. Following delivery, birth outcomes were obtained from medical records. Babies of depressed mothers weighed less, were born earlier and had lower Apgar scores than babies of nondepressed mothers. Depressed women had smaller social support networks and were less satisfied with support from social networks. We found no direct associations between perceived social support and birth weight. However, depressed women who rated their partners as less supportive had babies who were born earlier and had lower Apgar scores than depressed mothers with higher perceived partner support. Women’s perception of partner support appears to buffer infants of depressed mothers from potential adverse outcomes. These results are notable in light of the low-risk nature of our sample and point to the need for continued depression screening in pregnant women and a broader view of risk for adverse birth outcomes. The results also suggest a possible means of intervention that may ultimately lead to reductions in adverse birth outcomes.

Depression and anxiety among postpartum and adoptive mothers

Similar to biological mothers during the postpartum period, women who adopt children experience increased stress and life changes that may put them at risk for developing depression and anxiety. The purpose of the current study was to compare levels of depression and anxiety symptoms between postpartum and adoptive women and, among adoptive women, to examine associations between specific stressors and depressive symptoms. Data from adoptive mothers (n = 147), recruited from Holt International, were compared to existing data from postpartum women (n = 147). Differences in the level of depression and anxiety symptoms as measured by the Inventory of Depression and Anxiety Symptoms among postpartum and adoptive women were examined. Associations between specific stressors and depressive symptoms were examined among adoptive mothers. Postpartum and adoptive women had comparable levels of depressive symptoms, but adoptive women reported greater well-being and less anxiety than postpartum women. Stressors (e.g., sleep deprivation, history of infertility, past psychological disorder, and less marital satisfaction) were all significantly associated with depressive symptoms among adoptive women. The level of depressive symptoms was not significantly different between the two groups. In contrast, adoptive women experienced significantly fewer symptoms of anxiety and experienced greater well-being. Additionally, adoptive mothers experienced more depressive symptoms during the year following adoption when the stressors were present. Thus, women with these characteristics should be routinely screened for depression and anxiety.

One‐Day Behavioral Intervention in Depressed Migraine Patients: Effects on Headache

To determine whether a 1‐day behavioral intervention, aimed at enhancing psychological flexibility, improves headache outcomes of migraine patients with comorbid depression.

Validity of somatic symptoms as indicators of depression in pregnancy.

Somatic symptoms (e.g., fatigue, appetite changes, and sleep disruption) are common to both pregnancy and depression. The goal of the present study was to examine the validity of somatic symptoms as indicators of depression during pregnancy. The Inventory of Depression and Anxiety Symptoms (IDAS) was administered to a cross-sectional sample of 255 pregnant women as well as 820 women from five community-based samples, who served as a control group. Confirmatory factor analysis (CFA) was used to evaluate the fit of a single-factor model of depression in pregnant and community samples. Multigroup CFA was used to test the invariance of the factor loadings of eight depression-related symptom scales. The fit for a one-factor model was adequate for both the pregnant and community samples. All eight IDAS scales were valuable indicators of depression in the community group; however, Appetite Loss and Appetite Gain were poor indicators of depression among the pregnant women. The factor loadings for Lassitude and Appetite Gain were significantly weaker amongst the pregnant women than community women. The magnitude of the factor loadings for Insomnia and Well Being were significantly greater for the pregnant group. With the exception of appetite disturbance, somatic symptoms, though a common occurrence during pregnancy, are valid indicators of depression during pregnancy. When assessing for prenatal depression, somatic symptoms should not necessarily be dismissed as normative pregnancy experiences.