Simone N. Vigod

Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review.

Please cite this paper as: Vigod S, Villegas L, Dennis C‐L, Ross L. Prevalence and risk factors for postpartum depression among women with preterm and low‐birth‐weight infants: a systematic review. BJOG 2010;117:540–550.

Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women.

Mood disorders disproportionately affect women across the lifespan. Mood disorders in pregnancy and the postpartum period are common and have profound implications for women and their children. These include obstetric and neonatal complications, impaired mother–infant interactions, and, at the extreme, maternal suicide and infanticide. Because obstetrician–gynecologists are often the first (and sometimes the only) point of contact for young women in the health care system, familiarity with the presentation and treatment of depressive illness in the perinatal period is imperative. The goal of this review is to synthesize essential information on depressive illness in the perinatal period with a focus on its most common and severe presentations, major depressive disorder and bipolar disorder. Accurate diagnosis of unipolar major depressive disorder from bipolar disorder can facilitate the selection of the best possible treatment alternatives. Counseling may be sufficient for perinatal women who have mild to moderate depression, but women who are severely depressed are likely to require antidepressant treatment. Women with bipolar disorder are at high risk for relapse if mood stabilizer medication is discontinued, and they are vulnerable to relapse near the time of delivery. Comanagement of their care with psychiatrists will increase their chances of avoiding a recurrence of illness.

Transitional interventions to reduce early psychiatric readmissions in adults: systematic review

BACKGROUND Up to 13% of psychiatric patients are readmitted shortly after discharge. Interventions that ensure successful transitions to community care may play a key role in preventing early readmission. AIMS To describe and evaluate interventions applied during the transition from in-patient to out-patient care in preventing early psychiatric readmission. METHOD Systematic review of transitional interventions among adults admitted to hospital with mental illness where the study outcome was psychiatric readmission. RESULTS The review included 15 studies with 15 non-overlapping intervention components. Absolute risk reductions of 13.6 to 37.0% were observed in statistically significant studies. Effective intervention components were: pre- and post-discharge patient psychoeducation, structured needs assessments, medication reconciliation/education, transition managers and in-patient/out-patient provider communication. Key limitations were small sample size and risk of bias. CONCLUSIONS Many effective transitional intervention components are feasible and likely to be cost-effective. Future research can provide direction about the specific components necessary and/or sufficient for preventing early psychiatric readmission.

The impact of obesity on quality of life

An important association exists between obesity and mental illness that impacts all aspects of an individuals quality of life. This association can begin early in the developmental trajectory and we do not yet completely understand all the mechanisms linking obesity and mental illness. What we e do know is that physical health factors that often occur secondary to obesity, combined with societal attitudes toward those that are obese coupled with iatrogenic treatment factors linked to psychiatric pharmacotherapy and a number of biologic mediators result in an important and increasing common comorbidity. Recognizing this association is essential for the proper management of both conditions. The following review addresses this issue and provides clinical pearls to help deal with this issue.

Risk for postpartum depression associated with assisted reproductive technologies and multiple births: a systematic review

BACKGROUND It has been hypothesized that certain obstetrical populations, including women who conceive using assisted reproductive technologies (ART) and women with multiple births, may be at increased risk for postpartum depression. In this systematic literature review, we examine the published evidence for this hypothesis. METHODS The databases Medline, CINAHL, EMBASE, PsycINFO and the Cochrane Library were searched from their start dates through to April 1, 2009 using relevant keywords. All published, peer-reviewed articles in English, Spanish or French including a standardized assessment of depression administered between 2 and 52 weeks postpartum were considered for inclusion. Two independent reviewers abstracted and critically appraised a total of 13 eligible articles. RESULTS The data indicate little or no increased risk for postpartum depression among women who use ART to conceive. In contrast, most studies of adequate quality indicate that mothers of multiples may be at elevated risk for symptoms of depression. However, existing data do not permit differentiation between transient maternal distress and clinically significant postpartum depression. CONCLUSIONS Studies included in this review were often limited by small samples and lack of appropriate comparison groups, making further research in this area essential. In particular, lack of control for maternal psychiatric history and other important sociodemographic predictors of depression is a serious limitation of existing research on this topic. Further, the use of reproductive technologies and multiple births often co-occur, and few study designs enabled separation of the effects of these two variables. However, evidence of increased risk for symptoms of postpartum depression among women with multiple births, if confirmed, may warrant targeted interventions for this population.

Antipsychotic drug use in pregnancy: high dimensional, propensity matched, population based cohort study

Objective To evaluate maternal medical and perinatal outcomes associated with antipsychotic drug use in pregnancy. Design High dimensional propensity score (HDPS) matched cohort study. Setting Multiple linked population health administrative databases in the entire province of Ontario, Canada. Participants Among women who delivered a singleton infant between 2003 and 2012, and who were eligible for provincially funded drug coverage, those with ≥2 consecutive prescriptions for an antipsychotic medication during pregnancy, at least one of which was filled in the first or second trimester, were selected. Of these antipsychotic drug users, 1021 were matched 1:1 with 1021 non-users by means of a HDPS algorithm. Main outcome measures The main maternal medical outcomes were gestational diabetes, hypertensive disorders of pregnancy, and venous thromboembolism. The main perinatal outcomes were preterm birth (<37 weeks), and a birth weight <3rd or >97th centile. Conditional Poisson regression analysis was used to generate rate ratios and 95% confidence intervals, adjusting for additionally prescribed non-antipsychotic psychotropic medications. Results Compared with non-users, women prescribed an antipsychotic medication in pregnancy did not seem to be at higher risk of gestational diabetes (rate ratio 1.10 (95% CI 0.77 to 1.57)), hypertensive disorders of pregnancy (1.12 (0.70 to 1.78)), or venous thromboembolism (0.95 (0.40 to 2.27)). The preterm birth rate, though high among antipsychotic users (14.5%) and matched non-users (14.3%), was not relatively different (rate ratio 0.99 (0.78 to 1.26)). Neither birth weight <3rd centile or >97th centile was associated with antipsychotic drug use in pregnancy (rate ratios 1.21 (0.81 to 1.82) and 1.26 (0.69 to 2.29) respectively). Conclusions Antipsychotic drug use in pregnancy had minimal evident impact on important maternal medical and short term perinatal outcomes. However, the rate of adverse outcomes is high enough to warrant careful assessment of maternal and fetal wellbeing among women prescribed an antipsychotic drug in pregnancy.

Epidemiology of postpartum depressive symptoms among Canadian women: regional and national results from a cross-sectional survey.

Objectives: To describe national and regional prevalence rates for significant depressive symptoms in women after 12 weeks during the postpartum period, and to identify predictors of postpartum depressive symptoms during this later time period. Methods: Data from the Maternity Experiences Survey of the Canadian Perinatal Surveillance System were analyzed. Participants completed a computer-assisted telephone interview between 5 and 14 months during the postpartum period (n = 6421). Depressive symptomatology was measured using the Edinburgh Postnatal Depression Scale (EPDS ≥ 13). Proportions and odds ratios with 95% confidence intervals were calculated using bootstrap methods to account for sample design and weighting adjustments. Results: About 8% of Canadian women exhibited depressive symptoms past 12 weeks during the postpartum period. Prevalence rates varied between regions. In multivariable analysis, previous history of depression (OR 1.87; 95% CI 1.43 to 2.45, P < 0.001), low household income (OR 1.64; 95% CI 1.27 to 2.11, P < 0.001), low postpartum social support (OR 3.95; 95% CI 2.77 to 5.62, P < 0.001), stressful life events (OR 2.43; 95% CI 1.88 to 3.15, P < 0.001), interpersonal violence (OR 1.40; 95% CI 1.04 to 1.87, P = 0.02), and poor self-perceived maternal health (OR 4.48; 95% CI 3.15 to 6.38, P < 0.001) were independently associated with postpartum depressive symptoms. Regional differences in correlates of postpartum depressive symptoms were found. Conclusions: The finding that depression rates are elevated throughout the first postpartum year is important because of the known negative impact of postpartum depression (PPD). Targeted public health interventions may be needed to reduce the prevalence of PPD and its associated impact.

Can we identify mothers at-risk for postpartum anxiety in the immediate postpartum period using the State-Trait Anxiety Inventory?

BACKGROUND This study assessed the stability of maternal anxiety and concordance between State-Trait Anxiety Inventory (STAI) scores in the immediate postpartum period to 8 weeks postpartum. METHODS A population-based sample of 522 mothers completed the STAI at 1, 4, and 8 weeks postpartum. Sensitivity, specificity, and predictive power of the 1-week STAI in relation to identifying mothers with elevated STAI scores at 4 and 8 weeks was determined. Predictive power of the STAI was further assessed using odds ratios and receiver operator characteristic (ROC) curves. RESULTS At 1 week postpartum, 22.6% of mothers scored >40 on the STAI, decreasing to 17.2% at 4 weeks and 14.8% at 8 weeks. Using the cut-off score of >40, the 1-week STAI accurately classified 84.0% mothers at 4 weeks and 83.6% at 8 weeks with or without anxiety symptomatology. The 1-week STAI was significantly correlated to the 4-week (r=0.68, p<0.001) and 8-week (r=0.64, p<0.001) STAI. Mothers with a 1-week STAI score >40 were 15.2 times more likely at 4 weeks (95% CI=8.9-26.1) and 14.0 times more likely at 8 weeks (95% CI=7.9-24.8) to exhibit postpartum anxiety symptomatology. LIMITATIONS Psychiatric interviews were not completed in collaboration with the STAI and specific types of anxiety disorders were not identified. CONCLUSIONS A cut-off score of >40 on the STAI administered early in the postpartum period is recommended in a 2-phase identification program in order to not miss mothers with postpartum anxiety.

Maternal and newborn outcomes among women with schizophrenia: a retrospective population‐based cohort study

More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia.

Temporal trends in general and age-specific fertility rates among women with schizophrenia (1996-2009): A population-based study in Ontario, Canada

PURPOSE There is substantial evidence that women with schizophrenia in many parts of the world have fewer children than their peers. Our objective was to analyze recent trends in general and age-specific fertility rates among women with schizophrenia in Ontario, Canada. METHODS We conducted a repeated cross-sectional population-based study from 1996 to 2009 using population-based linked administrative databases for the entire province of Ontario. Women aged 15-49 years were classified into schizophrenia and non-schizophrenia groups in each successive 12-month period. Annual general and age-specific fertility rates were derived. RESULTS The general fertility rate (GFR) among women with schizophrenia was 1.16 times higher in 2007-2009 than in 1996-1998 (95% confidence interval [CI] 1.04-1.31). The annual GFR ratio of women with vs. without schizophrenia was 0.41 (95% CI 0.36-0.47) in 2009, which was slightly higher than the same ratio in 1996 of 0.30 (95% CI 0.25-0.35). Annual age-specific fertility rates (ASFR) increased over time among women with schizophrenia aged 20-24, 25-29, 35-39 and 40-44 years, but the increase was not always statistically significant. Among women aged 20-24 years, the ASFR ratio in women with vs. without schizophrenia was not significant by the end of the study period (0.93, 95% CI 0.70-1.22). CONCLUSIONS The general fertility rate among women with schizophrenia appears to have increased modestly over the past 13 years. Clinical care and health policy should consider new strategies that focus on the mental health of women with schizophrenia as new mothers, while optimizing healthy pregnancies and child rearing.