Mijke P. Lambregtse-van den Berg

Validation of the Edinburgh Depression Scale during pregnancy

BACKGROUND Untreated depression during pregnancy may have adverse outcomes for the mother and her child. Screening for depression in the general pregnant population is thus recommended. The Edinburgh Depression Scale (EDS) is widely used for postpartum depression screening. There is no consensus on which EDS cutoff values to use during pregnancy. The aim of the current study was to examine the predictive validity and concurrent validity of the EDS for all three trimesters of pregnancy. METHODS In a large unselected sample of 845 pregnant women, the sensitivity, specificity, and validity of the EDS were evaluated. The Composite International Diagnostic Interview (depression module) was used to examine the predictive validity of the EDS. The anxiety and somatization subscales of the Symptom Checklist 90 (SCL-90) were used to examine its concurrent validity. Only women with a major depressive episode were considered as cases. RESULTS The prevalence of depression decreased toward end term: 5.6%, 5.4%, and 3.4%. The EDS scores also decreased toward end term, while the SCL-90 subscale anxiety scores increased. The EDS showed high test-retest reliability and high concurrent validity with the SCL-90 anxiety and somatization subscales. The area under the receiver operating characteristic curve was high and varied between 0.93 and 0.97. A cutoff value of 11 in the first trimester and that of 10 in the second and third trimesters gave the most adequate combination of sensitivity, specificity, and positive predictive value. CONCLUSIONS The EDS is a reliable instrument for screening depression during pregnancy. A lower cutoff than commonly applied in the postpartum period is recommended.

Prevalence of autoimmune thyroid dysfunction in postpartum psychosis

BACKGROUND Postpartum psychosis is a life-threatening psychiatric emergency, which often occurs without significant premorbid symptoms. Although many studies have postulated an involvement of the immune and endocrine systems in the onset of postpartum psychosis, the specific aetiological factors have remained unknown. AIMS To examine the hypothesis that autoimmune thyroid dysfunction may be associated with the onset of postpartum psychosis. METHOD Thirty-one consecutive primiparous women with no prior psychiatric history were referred to our in-patient unit for postpartum psychosis. The control group (n = 117) comprised primiparous women with consecutive deliveries at a community practice. Blood samples were obtained from all participants at 4 weeks and 9 months postpartum. Thyroperoxidase antibody levels were quantified as immunological measures of autoimmune thyroid disease (AITD). Thyroid-stimulating hormone and free thyroxine levels were measured to assess clinical thyroid dysfunction. RESULTS At 4 weeks postpartum and prior to the initiation of mood stabiliser therapy, 19% of women with postpartum psychosis had AITD compared with only 5% in the control group. Women with both postpartum psychosis and AITD had a dramatically higher risk of progression to clinical thyroid dysfunction (67%) than control participants with AITD (20%). CONCLUSIONS Women with postpartum psychosis are at higher risk not only of AITD but also of clinical thyroid failure. These data implicate thyroid function as an important clinical outcome in patients with postpartum psychosis. Further, AITD represents a potentially strong aetiological factor for the development of postpartum psychosis. Therefore, screening for thyroperoxidase antibodies is warranted in patients with postpartum psychosis.

Grandparental anxiety and depression predict young children's internalizing and externalizing problems: the generation R study.

BACKGROUND Family history is a major risk factor for child problem behaviour, yet few studies have examined the association between grandparental psychiatric disorder and child problem behaviour. Results are inconsistent as to whether the effect of grandparental depression on child problem behaviour is independent of parental psychopathology. METHODS Mothers and their children participated in an ethnically Dutch subcohort of a population-based prospective cohort in the Netherlands. N = 816 (66%) mothers and n = 691 fathers participated in the prenatal interviews. N = 687 (84%) mothers and children and n = 565 (82%) fathers participated three years postpartum. (Grand)parental psychopathology was assessed during pregnancy of the mothers with the Family Informant Schedule and Criteria (FISC), the Composite International Diagnostic Interview (CIDI) and the Brief Symptom Inventory (BSI). Child behaviour was assessed with the Child Behavior Checklist (CBCL) by mother and father when the child was three years old. RESULTS Grandparental anxiety disorder predicted maternal reports of childrens internalizing problems (OR = 1.98, 95% C.I. (1.20, 3.28), p-value<0.01) and externalizing problems (OR = 1.73, 95% C.I. (1.04, 2.87), p-value = 0.03), independent of parental psychopathology. Results were similar for grandparental depression; internalizing OR = 1.75, 95% C.I (1.11, 2.75), p-value = 0.02 and externalizing OR = 1.67, 95% C.I. (1.05, 2.64) p-value = 0.03. However, grandparental psychopathology was not associated with childrens problem behaviour as reported by the father. LIMITATIONS Information on grandparental lifetime psychiatric disorder was assessed through a parental interview which may have led to an underestimation of the prevalence rates. CONCLUSIONS These results confirm the importance of a family history including not only the parental but also the grandparental generations.

Treatment of Psychosis and Mania in the Postpartum Period

Postpartum psychosis is a severe disorder that warrants acute clinical intervention. Little is known, however, about what interventions are most effective. The authors present treatment response and remission outcomes at 9 months postpartum using a four-step algorithm in patients with first-onset psychosis or mania in the postpartum period. Treatment involved the structured sequential administration of benzodiazepines, antipsychotics, lithium, and ECT. The outcome of clinical remission was examined in 64 women consecutively admitted for postpartum psychosis. Remission was defined as the absence of psychotic, manic, and severe depressive symptoms for at least 1 week. Women who remitted on antipsychotic monotherapy were advised to continue this treatment as maintenance therapy, and women who required both antipsychotics and lithium to achieve remission were maintained on lithium monotherapy. Relapse was defined as the occurrence of any mood or psychotic episode fulfilling DSM-IV-TR criteria. Using this treatment algorithm, the authors observed that nearly all patients (98.4%) achieved complete remission within the first three steps. None of the patients required ECT. At 9 months postpartum, sustained remission was observed in 79.7%. Patients treated with lithium had a significantly lower rate of relapse compared with those treated with antipsychotic monotherapy. Multiparity and nonaffective psychosis were identified as risk factors for relapse. The authors conclude that a structured treatment algorithm with the sequential addition of benzodiazepines, antipsychotics, and lithium may result in high rates of remission in patients with first-onset postpartum psychosis and that lithium maintenance may be most beneficial for relapse prevention.

An innovative screen-and-advice model for psychopathology and psychosocial problems among urban pregnant women: an exploratory study

Background: Increased adverse pregnancy outcomes related to psychiatric and psychosocial problems can be observed for urban areas when compared to national averages. We developed a personal digital assistant (PDA)-based self-report screening model that produces tailored intervention advices. After having adapted the model to local care pathways, we tested the reliability, validity and feasibility of the model in routine antenatal care. Methods: Observational study among pregnant women in a Dutch urban area included women with a booking visit. Women answered questions posed by the PDA-tool while waiting for their appointment. If the tool suggested specific interventions (screen result), this was discussed during booking visit. A randomly selected subsample of participants completed the questionnaire again at a subsequent pregnancy check (retest). After the study was conducted, prenatal caregivers and assistants were interviewed for feasibility judgments. Psychometric and diagnostic performance of this approach was established. Results: Response rate among invited pregnant women was 94% on weighted average (n = 621). Internal reliability ranged 0.88–0.90, test-retest reliability ranged 0.64–1.00. Positive predictive value was 86% and negative predictive value was 97%. No interpractice psychometrical differences were observed. Migrant women more often received an intervention advice than native women (p < 0.001). The approach was well accepted among prenatal caregivers for its time efficiency and patient-friendliness. Conclusion: Psychometric properties of our screen-and-advice tool were favorable under routine conditions, and the feasibility of this integral approach appeared good. The technical flexibility renders the model suitable for broader application. Local care pathways can easily be incorporated. We suggest implementation of this model in prenatal care in urbanized settings in order to make tailored mental healthcare broadly available.

Maternal smoking during pregnancy and child emotional problems: The relevance of maternal and child 5-HTTLPR genotype

Serotonin is involved in the development of neural circuits modulating emotional behavior. The short allele (s) of a polymorphism (5‐HTTLPR) of the serotonin transporter gene is a risk factor for psychopathology in the presence of environmental stressors. Maternal smoking is associated with growth restriction of the human fetal brain and adverse effects of nicotine on the developing serotonin system have been documented. We hypothesized that maternal smoking interacts with both child and mother 5‐HTTLPR genotype as a risk factor for later child emotional problems. In a sample of n = 1,529 mother–child dyads, smoking habits were assessed by questionnaires during pregnancy. Child emotional problems were measured by the Child Behavior Checklist at the childs age of 3 years. Maternal smoking during pregnancy significantly increased the risk for emotional problems in children carrying the s‐allele; β = 0.24, P = 0.03 (mother‐report), and β = 0.46, P = 0.001 (father‐report). In children heterozygous at 5‐HTTLPR and exposed to maternal prenatal smoking (n = 79) risk of emotional problems increased with each additional s‐allele the mother carried. The associations between 5‐HTTLPR and child emotional problems were not moderated by paternal prenatal smoking. These findings imply that the vulnerability for emotional problems in s‐allele carriers may already originate in fetal life.

Perceived sleep quality is worse than objective parameters of sleep in pregnant women with a mental disorder.

OBJECTIVE Disturbed sleep during pregnancy is associated with adverse obstetric outcomes and less mental well-being. In pregnant women with a mental disorder, who frequently suffer from sleep problems, it is unknown whether predominantly objective or subjective sleep quality is more affected. To clarify this, we compared objective and subjective parameters of sleep quality between patients and healthy controls during pregnancy. METHODS This observational study was embedded in an ongoing study among pregnant women with a mental disorder at the department of Psychiatry of Erasmus University Medical Center Rotterdam, the Netherlands. We compared 21 pregnant women with a confirmed mental disorder with 33 healthy controls (gestational age, 23-29 weeks). To measure objective parameters of sleep quality, all participants continuously wore a wrist actigraph for 7 days and nights. Subjective sleep quality was retrospectively assessed using the Pittsburgh Sleep Quality Index (PSQI) and on a daily basis with the Subjective Sleep Quality-scale (SSQ). Differences in parameters of sleep between patients and controls were tested using a multivariate linear regression analysis adjusted for parity, gestational age, educational level, and employment status. RESULTS Objective parameters of sleep quality and subjective sleep quality as assessed by the PSQI did not differ significantly between patients and controls. Daily sleep reports showed that, relative to controls, patients had a significantly worse average SSQ-score (5.2 vs. 7.6, adjusted β = 0.12, 95%CI = 0.03-0.53, p < 0.01). CONCLUSIONS Our exploratory study suggests that perceived sleep quality reported on a daily basis by pregnant women with a mental disorder is worse than the sleep quality as measured by wrist actigraphy.

Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis

Background For women suffering from an antepartum mental disorder (AMD), there is lack of evidence-based treatment algorithms due to the complicated risk-benefit analysis for both mother and unborn child. We aimed to provide a comprehensive overview of pharmacological and non-pharmacological interventions to treat AMD and performed a meta-analysis of the estimated treatment effect on the psychiatric symptoms during pregnancy. Methods MedLine, PsycINFO and Embase databases were searched by two independent reviewers for clinical trials with a control condition on treatment of women with AMD, i.e. major depressive (MDD), anxiety, psychotic, eating, somatoform and personality disorders. We inventoried the effect of the treatment, i.e. decrease of psychiatric symptoms at the end of the treatment or postpartum. We adhered to the PRISMA-protocol. Findings Twenty-nine trials were found involving 2779 patients. Trials studied patients with depressive disorders (k = 28), and anxiety disorders (k = 1). No pharmacological trials were detected. A form of psychotherapy, like Cognitive Behavioural Therapy (g = -0.61; 95%CI:-0.73 to -0.49, I2 = 0%; k = 7) or Interpersonal Psychotherapy (g = -0.67; 95%CI:-1.27 to -0.07; I2 = 79%; k = 4), holds robust benefit for pregnant women with MDD. Body-oriented interventions (g = -0.43; 95%CI:-0.61 to -0.25; I2 = 17%; k = 7) and acupuncture (g = -0.43; 95%CI:-0.80 to -0.06; I2 = 0%; k = 2) showed medium sized reduction of depressive symptoms. Bright light therapy (g = -0.59; 95%CI:-1.25 to 0.06; I2 = 0%; k = 2), and food supplements (g = -0.51; 95%CI:-1.02 to 0.01; I2 = 20%; k = 3) did not show significant treatment effects. One study was found on Integrative Collaborative Care. Conclusions This meta-analysis found a robust moderate treatment effect of CBT for MDD during pregnancy, and to a lesser extent for IPT. As an alternative, positive results were found for body-oriented interventions and acupuncture. No evidence was found for bright light therapy and food supplements. Only non-pharmacological trials on women with MDD were found. Research on a wider range of AMD is needed.

Successful five-item triage for the broad spectrum of mental disorders in pregnancy – a validation study

BackgroundMental disorders are prevalent during pregnancy, affecting 10% of women worldwide. To improve triage of a broad spectrum of mental disorders, we investigated the decision impact validity of: 1) a short set of currently used psychiatric triage items, 2) this set with the inclusion of some more specific psychiatric items (intermediate set), 3) this new set with the addition of the 10-item Edinburgh Depression Scale (extended set), and 4) the final set with the addition of common psychosocial co-predictors (comprehensive set).MethodsThis was a validation study including 330 urban pregnant women. Women completed a questionnaire including 20 psychiatric and 10 psychosocial items. Psychiatric diagnosis (gold standard) was obtained through Structured Clinical Interviews of DSM-IV axis I and II disorders (SCID-I and II). The outcome measure of our analysis was presence (yes/no) of any current mental disorder.The performance of the short, intermediate, extended, and comprehensive triage models was evaluated by multiple logistic regression analysis, by analysis of the area under the ROC curve (AUC) and through associated performance measures, including, for example, sensitivity, specificity and the number of missed cases.ResultsDiagnostic performance of the short triage model (1) was acceptable (Nagelkerkes R2=0.276, AUC=0.740, 48 out of 131 cases were missed). The intermediate model (2) performed better (R2=0.547, AUC=0.883, 22 cases were missed) including the five items: ever experienced a traumatic event, ever had feelings of a depressed mood, ever had a panic attack, current psychiatric symptoms and current severe depressive or anxious symptoms. Addition of the 10-item Edinburgh Depression Scale or the three psychosocial items unplanned pregnancy, alcohol consumption and sexual/physical abuse (models 3 and 4) further increased R2 and AUC (>0.900), with 23 cases missed. Missed cases included pregnant women with a current eating disorder, psychotic disorder and the first onset of anxiety disorders.ConclusionsFor a valid detection of the full spectrum of common mental disorders during pregnancy, at least the intermediate set of five psychiatric items should be implemented in routine obstetric care. For a brief yet comprehensive triage, three high impact psychosocial items should be added as independent contributors.

The role of depressive symptoms in the pathway of demographic and psychosocial risks to preterm birth and small for gestational age

OBJECTIVE depressive symptoms during pregnancy are associated with preterm birth (PTB) and small for gestational age (SGA). Depressive symptoms and PTB and SGA, however, share similar demographic and psychosocial risk factors. Therefore, we investigated whether depressive symptomatology is an independent risk factor, or a mediator in the pathway of demographic and psychosocial risks to PTB and SGA. DESIGN multicentre follow-up study. PARTICIPANTS AND SETTING pregnant women (n=1013) from midwifery practices, secondary hospitals and a tertiary hospital in three urban areas in the Netherlands. MEASUREMENTS initial risk factors and depressive symptoms were assessed with the Mind2Care instrument, including Edinburgh Depression Scale (EDS) during early pregnancy. Pregnancy outcomes were extracted from medical records. A formal mediation analysis was conducted to investigate the role of depressive symptoms in the pathway to PTB and SGA. FINDINGS a univariate association between depressive symptoms and PTB (OR:1.04; 95% CI:1.00-1.08) was observed. After adjusting for the risk factors educational level and smoking in the mediation analysis, this association disappeared. One educational aspect remained associated: low education OR: 1.06; 95%-CI:1.02-1.10. KEY CONCLUSIONS depressive symptomatology appeared no mediator in the pathway of demographic and psychosocial risks to PTB or SGA. The presumed association between depressive symptoms and PTB seems spurious and may be explained by demographic and psychosocial risk factors. IMPLICATIONS FOR PRACTICE for the prevention of PTB and SGA, interventions directed at demographic and psychosocial risk factors are likely to be of primary concern for clinicians and public health initiatives. As depressive symptoms and PTB and SGA share similar risk factors, both will profit.