Samantha Meltzer-Brody

Perinatal depression: a systematic review of prevalence and incidence.

OBJECTIVE: We systematically review evidence on the prevalence and incidence of perinatal depression and compare these rates with those of depression in women at nonchildbearing times. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, and Sociofile for English-language articles published from 1980 through March 2004, conducted hand searches of bibliographies, and consulted with experts. METHODS OF STUDY SELECTION: We included cross-sectional, cohort, and case-control studies from developed countries that assessed women for depression during pregnancy or the first year postpartum with a structured clinical interview. TABULATION, INTEGRATION, AND RESULTS: Of the 109 articles reviewed, 28 met our inclusion criteria. For major and minor depression (major depression alone), the combined point prevalence estimates from meta-analyses ranged from 6.5% to 12.9% (1.0-5.6%) at different trimesters of pregnancy and months in the first postpartum year. The combined period prevalence shows that as many as 19.2% (7.1%) of women have a depressive episode (major depressive episode) during the first 3 months postpartum; most of these episodes have onset following delivery. All estimates have wide 95% confidence intervals, showing significant uncertainty in their true levels. No conclusions could be made regarding the relative incidence of depression among pregnant and postpartum women compared with women at nonchildbearing times. CONCLUSION: To better delineate periods of peak prevalence and incidence for perinatal depression and identify high risk subpopulations, we need studies with larger and more representative samples.

Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder

The Davidson Trauma Scale (DTS) is a validated 17-item self-rating scale used in the diagnosis of post-traumatic stress disorder (PTSD), which is sensitive to the effects of treatment. It was felt that a shorter version of the scale might provide a better diagnostic screening tool. Subjects were drawn from a sample of 243 patients obtained from multiple cohorts that included a group of survivors of various forms of trauma, including natural disaster, rape and combat. All subjects had diagnostic assessments for PTSD with a clinical interview and completed the DTS. The data were randomly divided between two subsamples, and frequency and severity scores were calculated for the DTS. A four-item scale, the SPAN (named for its top four items: Startle, Physiological arousal, Anger, and Numbness), was developed. It demonstrated an efficiency of 0.88, sensitivity of 0.84, specificity of 0.91 and positive likelihood ratio of 9.1. In a replication sample, values were slightly lower but still acceptable (efficiency = 0.80). A subgroup of PTSD patients received either fluoxetine or placebo in a clinical trial, and a significant SPAN score improvement was observed on fluoxetine. The SPAN, which correlated significantly with the Impact of Events Scale, the Sheehan Disability Scale, and the Structured Interview of PTSD, was found to have a diagnostic accuracy of 88%.

Early Breastfeeding Experiences and Postpartum Depression

BACKGROUND: The first weeks after childbirth are a critical period for mother and newborn. Women may present with lactation failure and postpartum depression. It is unclear how a womans early breastfeeding experiences relate to postpartum depression. OBJECTIVE: We estimated the association between early breastfeeding experiences and postpartum depression at 2 months. METHODS: We modeled this association with logistic regression in a secondary analysis of data from the Infant Feeding Practices Study II. We assessed postpartum depression status with the Edinburgh Postnatal Depression Scale. RESULTS: In the neonatal period, 2,586 women reported ever breastfeeding, among whom 223 (8.6%) met criteria for major depression (Edinburgh Postnatal Depression Scale 13 or greater) at 2 months postpartum. Women who disliked breastfeeding in the first week were more likely to experience postpartum depression at 2 months (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.04–1.93) adjusting for maternal age, parity, education, ethnicity, and postnatal WIC participation. Women with severe breastfeeding pain in the first day (adjusted OR 1.96, 95% CI 1.17–3.29), the first week (adjusted OR 2.13, 95% CI 0.74–6.15 compared with no pain), and the second week (adjusted OR 2.24, 95% CI 1.18–4.26 compared with no pain) were more likely to be depressed. Breastfeeding help appeared protective among women with moderate (adjusted OR 0.22, 95% CI 0.05–0.94) or severe (adjusted OR 0.17, 95% CI 0.04–0.75) pain with nursing. CONCLUSION: Women with negative early breastfeeding experiences were more likely to have depressive symptoms at 2 months postpartum. Women with breastfeeding difficulties should be screened for depressive symptoms. LEVEL OF EVIDENCE: II

Trauma and Posttraumatic Stress Disorder in Women With Chronic Pelvic Pain

OBJECTIVE: To examine the effect of abuse history, other major trauma, and posttraumatic stress disorder (PTSD) on medical symptoms and health-related daily functioning in women with chronic pelvic pain. METHODS: We administered a questionnaire to 713 consecutive women seen in a referral-based pelvic pain clinic. RESULTS: We found that 46.8% reported having either a sexual or physical abuse history. A total of 31.3% had a positive screen for PTSD. Using regression and path analysis, controlling for demographic variables, we found that a trauma history was associated with worse daily physical functioning due to poor health (P<.001), more medical symptoms (P<.001), more lifetime surgeries (P<.001), more days spent in bed (P<.001), and more dysfunction due to pain (P<.001). Furthermore, a positive screen for PTSD was highly related to most measures of poor health status (P<.001) and somewhat explained the trauma-related poor health status. CONCLUSION: The association of trauma with poor health may be due in part to the development of PTSD resulting from trauma. These findings demonstrate the importance of screening for trauma and PTSD in women with chronic pelvic pain. LEVEL OF EVIDENCE: II

Association Between Maternal Mood and Oxytocin Response to Breastfeeding

BACKGROUND Postpartum depression is associated with reduced breastfeeding duration. We previously hypothesized that shared neuroendocrine mechanisms underlie this association. We sought to measure the association between maternal mood and neuroendocrine response to breastfeeding. METHODS We conducted a longitudinal cohort study of women recruited during pregnancy who intended to breastfeed. Baseline depression and anxiety history were assessed with a structured clinical interview. We measured mood symptoms using validated psychometric instruments, and we quantified affect and neuroendocrine responses to breastfeeding during laboratory visits at 2 and 8 weeks postpartum. RESULTS We recruited 52 women who intended to breastfeed, among whom 47 completed 8-week follow-up. Duration and intensity of breastfeeding through 8 weeks were similar among mothers with lower versus higher anxiety and depression scores. In the third trimester, oxytocin was inversely correlated with Edinburgh Postnatal Depression Scale (EPDS) score (p=0.03). We did not find differences in neuroendocrine profile during breastfeeding at 2 weeks postpartum. Among the 39 women who breastfed at 8 weeks postpartum, oxytocin area under the curve during breastfeeding was inversely correlated with maternal EPDS and STAI-State and STAI-Trait anxiety scores (all p≤0.01). Higher anxiety and depression scores was further associated with lower oxytocin (group p<0.05) during feeding. During feeding at both visits, higher anxiety and depression scores were also associated with more negative affect: mothers reported feeling less happy and more depressed, overwhelmed, and stressed during feeding than women with lower scores. CONCLUSION Symptoms of depression and anxiety were associated with differences in oxytocin response and affect during breastfeeding.

Psychiatric Disorders With Postpartum Onset: Possible Early Manifestations of Bipolar Affective Disorders

CONTEXT Childbirth has an important influence on the onset and course of bipolar affective disorder, and it is well established that there may be a delay of many years before receiving a diagnosis of bipolar disorder following an initial episode of psychiatric illness. OBJECTIVE To study to what extent psychiatric disorders with postpartum onset are early manifestations of an underlying bipolar affective disorder. DESIGN Survival analyses were performed in a register-based cohort study linking information from the Danish Civil Registration System and the Danish Psychiatric Central Register. SETTING Denmark. PARTICIPANTS A total of 120,378 women with a first-time psychiatric inpatient or outpatient contact with any type of mental disorder excluding bipolar affective disorder. MAIN OUTCOME MEASURES Each woman was followed up individually from the day of discharge, with the outcome of interest being an inpatient or outpatient contact during the follow-up period with a first-time diagnosis of bipolar affective disorder. RESULTS A total of 3062 women were readmitted or had an outpatient contact with bipolar affective disorder diagnoses. A postpartum onset of symptoms within 0 to 14 days after delivery predicted subsequent conversion to bipolar disorder (relative risk = 4.26; 95% CI =3.11-5.85). Approximately 14% of women with first-time psychiatric contacts during the first postpartum month converted to a bipolar diagnosis within the 15-year follow-up period compared with 4% of women with a first psychiatric contact not related to childbirth. Postpartum inpatient admissions were also associated with higher conversion rates to bipolar disorder than outpatient contacts (relative risk = 2.16; 95% CI = 1.27-3.66). CONCLUSIONS A psychiatric episode in the immediate postpartum period significantly predicted conversion to bipolar affective disorder during the follow-up period. Results indicate that the presentation of mental illness in the early postpartum period is a marker of possible underlying bipolarity.

Long-term outcome after acute treatment with alprazolam or clonazepam for panic disorder.

The relative effectiveness of the available treatments for panic disorder may best be understood in the context of the longitudinal course of the disorder. This study examines a number of clinically relevant issues, including long-term outcome after acute treatment, the proportion of patients remaining on single-agent treatment or requiring multiple medications or nonpharmacologic interventions over time, evidence for dose escalation during maintenance high-potency benzodiazepine therapy, and predictors of acute and long-term response to treatment. Fifty-nine panic disorder patients originally randomized to treatment in a controlled trial comparing alprazolam, clonazepam, and placebo were reevaluated in a follow-up study. At a mean follow-up of 1.5 years, 78% of patients remained on medication and the mean dosage of alprazolam and clonazepam did not increase. Our data suggest that most patients maintain benefit with long-term pharmacotherapy but that residual symptomatology may require more intensive or additional treatment strategies. Response at the endpoint of the acute trial was significantly associated with pretrial baseline Clinical Global Impression Scale score and the presence of dysthymia. Poor outcome at follow-up was associated with total duration of the disorder, agoraphobic subtype, and the presence of comorbid social phobia. We underscore the potential importance of comorbid affective and anxiety disorders as well as phobic patterns in determining long-term response to treatment.

Failed Lactation and Perinatal Depression: Common Problems with Shared Neuroendocrine Mechanisms?

In the early postpartum period, mother and infant navigate a critical neuroendocrine transition from pregnancy to lactation. Two major clinical problems that occur during this transition are failed lactation and perinatal mood disorders. These disorders often overlap in clinical settings. Failed lactation is common. Although all major medical organizations recommend 6 months of exclusive breastfeeding, only 13% of women in the United States achieve this recommendation. Perinatal mood disorders affect 10% of mothers, with substantial morbidity for mother and child. We hypothesize that shared neuroendocrine mechanisms contribute to both failed lactation and perinatal mood disorders. In this hypothesis article, we discuss data from both animal models and clinical studies that suggest neuroendocrine mechanisms that may underlie these two disorders. Research to elucidate the role of these underlying mechanisms may identify treatment strategies both to relieve perinatal depression and to enable women to achieve their infant feeding goals.

Heterogeneity of postpartum depression: a latent class analysis

BACKGROUND Maternal depression in the postpartum period confers substantial morbidity and mortality, but the definition of postpartum depression remains controversial. We investigated the heterogeneity of symptoms with the aim of identifying clinical subtypes of postpartum depression. METHODS Data were aggregated from the international perinatal psychiatry consortium Postpartum Depression: Action Towards Causes and Treatment, which represents 19 institutions in seven countries. 17,912 unique subject records with phenotypic data were submitted. We applied latent class analyses in a two-tiered approach to assess the validity of empirically defined subtypes of postpartum depression. Tier one assessed heterogeneity in women with complete data on the Edinburgh postnatal depression scale (EPDS) and tier two in those with postpartum depression case status. FINDINGS 6556 individuals were assessed in tier one and 4245 in tier two. A final model with three latent classes was optimum for both tiers. The most striking characteristics associated with postpartum depression were severity, timing of onset, comorbid anxiety, and suicidal ideation. Women in class 1 had the least severe symptoms (mean EPDS score 10·5), followed by those in class 2 (mean EPDS score 14·8) and those in class 3 (mean EPDS score 20·1). The most severe symptoms of postpartum depression were significantly associated with poor mood (mean EPDS score 20·1), increased anxiety, onset of symptoms during pregnancy, obstetric complications, and suicidal ideation. In class 2, most women (62%) reported symptom onset within 4 weeks postpartum and had more pregnancy complications than in other two classes (69% vs 67% in class 1 and 29% in class 3). INTERPRETATION PPD seems to have several distinct phenotypes. Further assessment of PPD heterogeneity to identify more precise phenotypes will be important for future biological and genetic investigations. FUNDING Sources of funding are listed at the end of the article.

Elevated Corticotropin Releasing Hormone (CRH) during Pregnancy and Risk of Postpartum Depression (PPD)

CONTEXT Perinatal depression has a prevalence of 10% with devastating consequences for mother and baby. The prospective identification of those at risk for postpartum (PPD) or prenatal (PND) depression has led to biomarker searches in pregnancy. There are conflicting reports of associations between midpregnancy placental CRH (pCRH) and PPD or PND. OBJECTIVE The objective of the study was to quantify the association of maternal pCRH with PPD and PND. DESIGN This was a prospective cohort study (the Pregnancy, Infection, and Nutrition Study). SETTING The study was conducted at a prenatal clinics at the University of North Carolina at Chapel Hill. PATIENTS Patients included 1230 pregnant women. MAIN OUTCOME MEASURES The relationship between pCRH at less than 20 wk and 24-29 wk and maternal depression assessed in pregnancy [Center for Epidemiologic Studies Depression Scale (CES-D)] and postpartum (12 wk and 1 yr) with the Edinburgh Postnatal Depression Scale (EPDS). RESULTS At 24-29 wk, 24.8% of women had CES-D score of 17 or greater, and 9.7% had a CES-D score of 25 or greater. At 12 wk postpartum, 18.2% of women had an EPDS score of 10 or greater and 7.6% had an EPDS score of 13 or greater. CRH measures at less than 20 wk and 24-29 wk were inversely correlated with a CES-D score at 24-29 wk (n = 1080, P < 0.05 and P < 0.01, respectively). Pregnancy pCRH was not correlated with the EPDS score at 12 wk (n = 484) or 1 yr postpartum (n = 391). In covariate-adjusted models, higher pCRH was not associated with a CES-D of 17 or greater at 24-29 wk (odds ratio 0.88 per sd change in pCRH at 24-29 wk, 95% confidence interval 0.76-1.03). There was no association between log CRH at 24-29 wk and PPD (covariate-adjusted odds ratio per sd 0.99, 95% confidence interval 0.69-1.42). CONCLUSION Higher midpregnancy pCRH was not associated with an increased risk of PND or PPD.