Baby blues: characterization and influence of psycho-social factors

BACKGROUND: Within days following birth, most women are showing signs of mood changes, commonly named baby blues. Due to the frequency of this condition, baby blues is considered as a physiological state probably associated to biological modifications. Some studies have shown an existing link between the intensity of the baby blues and post-partum mood disorder. Therefore, it seems important to report and explore in more details the clinical background related the condition. The aim of this study was to demonstrate the possibility of a link between the intensity of the baby blues and some specific factors like maternal self-esteem, maternal childcare stress and social background, and also to define the symptoms of the baby blues from core dimensions in mood disorders. METHOD: Mothers were recruited few hours before giving birth in a teaching hospital. At the third day following birth, an appointment was made to obtain the necessary information (past medical history and social history) and history of previous mood disorders. The mood was evaluated from the scale of the intensity of baby blues from Kennerly and Gath (1989). Moreover, evaluations at day 3 and week 6 post birth of self-esteem in relation to motherhood (Maternal self-report Inventory from Shea and Tronick, 1988), stress in relation with the care of the baby (Childcare Stress Inventory from Cutrona, 1983) and the social support (Social Support scale from Bruchon-Schweitzer, 1998) were undertaken. RESULTS: 95 women were included in the final sample. The intensity of the baby blues was explained by the type of pregnancy (p=0.002), a low maternal self-esteem (p=0.025), high levels of stress in relation to the care of the baby (p=0.074). The basic clinical characteristic of the baby blues seems to be due to an increase in the emotional reaction with a sharp feelings, leading to a lability rather than an affect sad tonality. CONCLUSION: The baby blues seems to be a physiological process whereby the intensity is influenced by psychological factors. Consequently the diminution of self-esteem with motherhood and the increase of stress in relation to the care of the baby appeared to be significant factors in the intensity of the baby blues. Moreover, the clinical characteristics found in this study implies that the baby blues is more related to hypomania rather than to depression syndrome. This non-pathological state could be the first stage leading to a puerperal psychosis in predisposed women, which is mainly characterized by manic symptoms.     

Association between the intensity of childbirth pain and the intensity of postpartum blues

AIM: The aim of this study was to highlight a link between childbirth pain and mood disorders in the immediate postpartum. METHOD: We met 43 women at three days postpartum in a maternity unit in Toulouse (France) between January and April 2004. The mean age of the mothers was 30 years (S.D., 4.8 years; range, 18-39 years). Mothers were excluded if they did not speak French, if they had past psychiatric history, and if their baby was premature, ill, or stillborn. Pain was measured using a French version of the McGill pain questionnaire (Melzack, 1975) [Br J Psychiatry 171 (1997) 550-555]. This questionnaire called questionnaire douleur Saint-Antoine (QDSA) is composed of 58 words and 16 classes (Boureau et at., 1984) [Thérapie 39 (1984) 119-129]. Classes 1-9 provide data on the sensory qualities of pain while Classes 10-16 reflect affective characteristics. Blues symptoms was assessed with the French version of the maternity blues questionnaire of Kennerley and Gath (1989) [Br J Psychiatry 145 (1984) 620-625]. For each 28 items women have to decide how much change there is from their usual self, by ticking one choice out of five, from "much less than usual" to "much more than usual". We used the French version of the EPDS (Cox et al., 1987) [Br J Psychiatry 150 (1987) 782-786]. This scale was used to assess the intensity of depressive mood. RESULTS: The results revealed a significant positive correlation between the pain scores and the "maternity blues" questionnaire scores, and between pain scores and EPDS score at three days postpartum. This study shows a stronger association between intensity of postpartum blues and affective aspect of childbirth pain (r=0.48; p<0.05) than between blues and sensorial aspect of pain (r=0.40; p<0.05). The level of depressive mood was found to be associated with affective (r=0.32; p<0.05) but not with sensory qualities of childbirth pain (r=0.28; p<0.05). In a multiple regression analysis predicting intensity of postpartum blues, we entered sensorial and affective scores of QDSA, age, and postpartum blues scores. The subjects to predictors ratio was adequate for multiple regression analysis as it was around the traditional guideline of at least ten participants per predictor [Howell DC. Statistical methods for psychology. Fourth ed. Duxbury press; 1997]. This model accounted for 31% of the variance of intensity of blues (F3,39=5.9, p=0.002). Affective dimension of pain was the only significant predictor (p=0.36, p=0.047). In another multiple regression analysis predicting intensity of depressive mood, we entered the same predictors. This model accounted for 20% of the variance of blues intensity (F3,39=3.26, p=0.03). Age was the only significant predictor (beta=-0.31, p=0.04). These results confirm our hypothesis that intensity of the childbirth pain is associated with mood disorders in the immediate postpartum. Several explications can be advanced. First, maternity blues could be a reaction to stress caused by childbirth pain. Moreover, pain can be felt as a failure for women who prepared themselves to a painless labor. Indeed, the prepared childbirth training pretends to give women the ability to overcome pain through physical and mental training. Thus, their responsibility in coping with the labor is heavy and might make them feel guilty if they fail. In addition, since "the labor itself should be experienced as a positive moment" [Chertock L. Féminité et maternité: étude clinique et expérimentale sur l'accouchement sans douleur. Paris: Desclée de Brouwer; 1996], pain might be at the origin of a great disappointment [Acta Obstet Gynecol Scand 83 (2004) 57-61]. It should be noted that we used the QDSA as a measure of past pain and not as a measure of immediate pain, as Melzack recommended [Pain 1 (1975) 277-299]. CONCLUSION: According to the results of this study, our hypothesis assuming a link between the intensity of labor pain and mood disorders in early postpartum appears to be confirmed. The intensity of postpartum blues is the best predictor of postnatal depression. Hence, knowledge of the risk factors, such as pain, could help to improve the efficiency of detection, and let professionals focus on the psychological impact of labor and especially on post-traumatic stress disorders.     

Sequential serotonin and noradrenalin associated processes involved in postpartum blues

OBJECTIVE: We investigated whether postpartum blues was related to changes in parameters of noradrenergic and serotonergic functioning. METHODS: From 26 healthy pregnant women blood was collected at the end of pregnancy and 5 days and 6 weeks postpartum. Serotonergic parameters were: platelet serotonin content; paroxetine binding to platelet membranes as an index of serotonin transporter activity; the serotonin precursor tryptophan in proportion to the large neutral amino acids, as an estimate of its cerebral influx. Noradrenergic indices were the noradrenaline precursor tyrosine and its metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG). The Kennerly and Gath blues questionnaire was applied at day five postpartum. RESULTS: The incidence of postpartum blues was 30%. The tryptophan ratio and serotonin content of platelets were decreased (p<0.01) at day five postpartum in all women. Bmax paroxetine at day five was correlated with blues score (beta=0.460; p=0.031). MHPG levels at 6 weeks were increased in women with blues (p<0.001). In a regression model MHPG at 6 weeks was related to blues score (beta=0.477; p=0.002) and MHPG at day five (beta=0.550; p=0.001), explaining >50% of the variation (R2=0.588; p<0.001). CONCLUSIONS: A decreased serotonergic activity was found at the fifth day postpartum in all subjects. Increased SERT activity, reflected by higher paroxetine binding to platelets might be involved in the onset of blues. The elevated MHPG levels in women with blues are compatible with a higher stress sensitivity, or a decreased stress coping in those and is suggested to be involved with the onset of depression.     

Postpartum blues: salivary cortisol and psychological factors

The relationships between several psychological variables and salivary cortisol levels were investigated in 70 young mothers throughout the first five days following the delivery of a healthy baby. We hypothesized that postpartum blues is associated with ineffective coping strategies, high anxiety levels, and elevated salivary cortisol concentrations. Data analysis revealed that symptoms of postpartum blues occurred more frequently in women who reported high levels of trait-anxiety, passive coping strategies, marital dissatisfaction, or acceptance of their role as a mother. These women had elevated morning levels of cortisol on those days on which the symptoms appeared in contrast to those days without symptoms as well as in contrast to those women who did not experience postpartum blues.     

Prospective study of postpartum blues. Biologic and psychosocial factors

Potential biologic and psychosocial causative factors for the postpartum blues were tested in a prospective study of 182 women followed up from the second trimester of pregnancy until postpartum week 9. Personal and family history of depression, depressive symptoms, stressful life events, and social adjustment were all assessed during the second trimester. Levels of progesterone, prolactin, estradiol, free and total estriol, and free and total cortisol were measured on several occasions during late pregnancy and early puerperium. Obstetric and child-care stressors and the postpartum blues were assessed after delivery. Predictors of the postpartum blues were personal and family history of depression, social adjustment, stressful life events, and levels of free and total estriol. Our results support the hypothesis that the postpartum blues is within the spectrum of affective disorders.     

Depressed mood during pregnancy and the puerperium: clinical recognition and implications for clinical practice

Mild to moderate depression is common among women during the first 3 months postpartum. The authors studied 20 normal pregnant women in the hope of finding valid predictors of postpartum mood disorder. The subjects rated their level of emotions and various depressive symptoms at 26 and 36 weeks of pregnancy and filled out a brief questionnaire about the emotional circumstances of their pregnancy. The mood scales were repeated at 2 days and 6 weeks postpartum, along with a clinical interview. The antepartum mood scale identified women with postpartum depression and differentiated this condition from the more common, transient postpartum blues. Certain psychosocial variables also predicted postpartum distress. The authors discuss the implications of these findings, emphasizing the feasibility and necessity of routine screening for mood disturbances in prenatal and puerperal women.     

Psychosocial factors associated to depressive episodes with hospitalization in women: a case-control study

The part played by psychosocial factors has frequently been studied in mental disorders whether as protective factors or as vulnerability factors, using variously adequate methods. A large body of research has shown that poor social support or poor self-esteem or presence of stressful life events could play a large part in triggering disorders. The importance of socioeconomic factors in mental illness is so great that such factors (unemployment, insecurity in employment, homelessness, lower social classes, low income) skew the studies in which they are not considered. In this study, in order to take into account these methodological problems, the study of psychosocial factors was undertaken in a standardized clinical manner and on a relatively socially privileged population. METHODS: Two homogeneous samples for several variables, using a case-control approach have been formed. A group of hospitalized women for "neurotic" depressive disorders, aged 30-50 (n=59) was systematically recruited in a psychiatric hospital located in the Paris area depending on MGEN (Mutuelle Générale de l'Education Nationale). The control group (n=76) was recruited among the 75 000 individuals in the Paris area registered as members of MGEN. A large group of women received a physical and mental health questionnaire for initial screening, the CIDIS (Composite Diagnostic Interview Simplified), by post. Among the 395 women that did not show mental disorders, a group of 90 was examined a second time using a more discriminating tool: the SCAN (Schedule for Clinical Assessment in Neuropsychiatry). In fine, the control group was based on 76 women that did not show and had never shown any mental disorders. To assess neurotic mental disorders in a clinical standardized manner, the SCAN (Schedule for Clinical Assessment in Neuropsychiatry) was used for inpatients. Scores were processed by CATEGO software which enables subjects to be classified according to the ICD-10 system. Events and difficulties experienced by subjects were recorded using the LEDS (Life Events and Difficulties Schedule). The clinicians that interviewed subjects and collected date were trained beforehand by Harris. The Brown and Haris methodology was used to rate subjects' responses and to classify events and difficulties. To assess and measure self-esteem and social support two check-lists elaborated and implemented by Pearlin were used. Means were compared using Student t test and frequencies using the c2 method (Yates'correction or Fisher exact test when necessary) to analyse independent associated factors. A multivariate logistic analysis was performed to identify significant variables. The association between factors and mental pathology studied was expressed with an odds ratio (OR) with the 95% confidence interval. RESULTS: Compared to the control group, the hospitalized patients reported higher levels of exposure to six factors: practising an intermediate profession (p=0.051), living alone (OR=4, 38); low self-esteem (OR=40, 96); low social support (OR=6, 46); having experienced at least one severe event (OR=2,45), at least one difficulty lasting 6 Months or more (OR=25, 57) and at least one provoking agent (a severe event or a major difficulty) (OR=3,49). These six variables were considered as potential associated factors to "neurotic depressive disorders" and thus entered into a logistic regression analysis. From these six variables, four may be considered as psychosocial associated factors in "neurotic depressive disorders": poor self-esteem is the highest risk factor (OR=71,43), and having experienced at least one difficulty (OR=15,75). Having poor social support and having experienced one or more "provoking agents" (one severe event or one major difficulty lasting 24 Months or more) correspond to approximatively OR=3. DISCUSSION: Following this study, four psychosocial associated factors in depressive episodes can be considered as being risk factors for "neurotic depressive disorders". In the literature psychosocial factors are frequently considered to be factors that possess a certain independence. This idea is discussed in the full article.     

The prevalence of postpartum depression

Background Little is known about the prevalence of clinically significant postpartum depression in women of varying social status. The purpose of the present study was to examine the prevalence of postpartum depression as a function of three indices of social status: income, education and occupational prestige. Method A sample of 4,332 postpartum women completed a demographic interview and the Inventory to Diagnose Depression, a self-report scale developed to identify a major depressive episode in accordance with DSM diagnostic criteria. Logistic regression was used to assess the relative significance of the three social status variables as risk factors for postpartum depression controlling for the effects of correlated demographic variables. Results In the logistic regression, income, occupational prestige, marital status, and number of children were significant predictors of postpartum depression controlling for the effects of other related demographic characteristics. The Wald Chi Square value for each of these significant predictors indicates that income was the strongest predictor. Conclusions The prevalence of postpartum depression was significantly higher in financially poor relative to financially affluent women. Maternal depression screening programs targeting women who are financially poor are well placed. Future research is needed to replicate the present findings in a more ethnically diverse sample that includes the full age range of teenage mothers.     

A study of the Edinburgh Postnatal Depression Scale (EPDS) on 859 mothers: detection of mothers at risk for postpartum depression

The postpartum is a high-risk period for the occurrence of anxious and depressive episodes. Indeed, during the first few days after delivery, mothers can present postpartum blues symptomatology: fatigue, anxiety, disordered sleeping and a changing mood. Postpartum depression is characterised by a changing mood, anxiety, irritability, depression, panic and obsessional phenomena. It occurs in approximately 10 to 20% mothers. The exact prevalence depending on the criteria used for detection. The first symptoms usually appear between the fourth and sixth week postpartum. However, postpartum depression can start from the moment of birth, or may result from depression evolving continuously since pregnancy. We can add that the intensity of postpartum blues is a risk factor that can perturb maternal development. So it is important for health professionals to dispose of predictive tools. This study is a validation of the French version of the EPDS. The aims of the study were to evaluate the postpartum depression predictive value at 3 days postpartum and to determine a cut-off score for major depression. Subjects participating in this study were met in 3 obstetrical clinics in, or in the vicinity of, Toulouse. Mothers with psychological problems, under treatment for psychological problems or mothers whose babies present serious health problems were excluded from the study. The EPDS was presented to 859 mothers (mean age=30.3; SD=4.5) met at one of the clinics at 3 days postpartum (period 1). They had an EPDS mean score of 6.4 (SD=4.6); 258 (30%) mothers had an EPDS score 9. 82.6% of these mothers experienced a natural childbirth and 17.3% a caesarean section; 51.5% gave birth to their first child, 36.2% to their second child and 12.3% to their third or more. All subjects were given a second EPDS with written instructions to complete the scale during the period 4 to 6 weeks postpartum and return it for analysis (period 2). Between the 4 to 6 weeks postpartum period, 722 mothers replied again to the EPDS. 131 mothers had an EPDS score 11 (mean age=30.3; SD=4.8). They had an EPDS mean score of 13.6 (SD=3.3). Mothers with probable depression were interviewed and assessed, using the Mini (Mini Neuropsychiatric Interview, Lecrubier et al. 1997), the SIGH-D (Structured Interview Guide for the Hamilton Depression Scale) and the BDI (Beck Depression Inventory) in order to diagnose a major depressive episode. They had a HDRS mean score of 13.7 (SD=5.1) and a BDI mean score of 13.6 (SD=5). At 3 days postpartum, we observed that 258 mothers (30%) had an EPDS scores 9 and 164 mothers (19%) had an EPDS scores 11. Between 4 and 6 weeks postpartum, we observed 18.1% of postpartum depression (EPDS 11) and 16.8% (EPDS 12) of major postpartum depression. The analysis of the sensitivity and the specificity at 3 days postpartum provides a cut-off score of 9 (Sensibility: 0.88) (Specificity: 0.50) as predictive of postpartum depression, for this cut-off score, the type I error is low (5.8%) but the type II error is more higher (18.9%). The analysis of the sensitivity and the specificity between 4 and 6 weeks postpartum provides a cut-off score of 12 (Sensibility: 0.91) (Sensibility: 0.74) for the detection of major postpartum depression. Factor analysis shows at 3 days postpartum that the internal structure of the scale is composed of two subscales. The first factor F1 "anxiety" accounts 28% of the variance and the second factor F2 "depression" accounts 20% of the variance. Between 4 and 6 weeks postpartum, factor analysis suggests an unidimensional model in the evaluation of postpartum depression which is better than a two factor model. This factor accounts 40% of the variance. The scale has a good predictive value, and we can observe a significant correlation with the EPDS periods 1 and 2 (r=0.56; p<0.05). This result shows that the depressive mothers mood intensity predicts a future depressive risk. Furthermore, correlations between EPDS and BDI (r=0.68; p<0.05) and EPDS and HDRS (r=0.67; p<0.05) show a good convergent validity. The reliability study confirms the good internal consistency of the EPDS, at 3 days postpartum and in the postpartum depression -symptomatology evaluation (Cronbach's Alpha>0.80). In conclusion, this scale demonstrates good validity and is fast and easy use in obstetrical services, allowing early detection of women who risk to develop postpartum depression and, in the first week of postpartum, of mothers who suffer from a major postpartum depression. The use of the EPDS for an early screening of the risk of postnatal depression which is essential considering the consequences that postnatal depression can have on the development of the infant, on the quality of the relationship within the couple and on other social relationships. Mothers at risk for postnatal depression should be controlled and surveyed by the health professionals in obstetrical clinics.     

Endocrine study of the maternity blues

Tadaharu Okano and Junichi Nomura : Endocrine Study of The Maternity Blues. Prog. Neuro-Psychopharmacol. & Biol. Psychiat. 1992, 16(6): 921–932.

1. 1. The relationship between several psychological variablesandadrenocortical function of the blues is examined in a prospective study of 47 Japanese women.

2. 2. Psychological measures, including the psychiatric interview and assessment of the Schedule for Affective Disorders and Schizophrenia (SASD), the Research Diagnostic Criteria (RDC) and self-rating scales, were administered at the 36th week of pregnancy, on the 3rd or 4th day postnatal and one month after delivery.

3. 3. Twelve subjects (25.5%) were diagnosed as having the blues on the Stein's scale. Women who developed the blues had siginificantly higher serum bound cortisol than the non-blues group. No significant correlation was obtained between the incidence of the blues and obstetric variables.

4. 4. At one month after delivery, four women (8.5%) were diagnosed as postpartum depression according to the RDC. Our finding that there was no consistent obstetric factor which predisposes women to develop the blues support the hypothesis that hyperadrenocorticalism is important in the genesis of this syndrome.

Screening and intervention for depressive mothers of new-born infants]

BACKGROUND AND THE AIM OF THE STUDY: Postnatal depression is a key concept for mother-infant mental health. Evidence of its impact on mother-infant relationship has been increasingly demonstrated in recent years. Therefore optimal intervention is important for women and their babies' mental health. Identifying risk factors of postnatal depression and developing screening system are needed. Study I Hospital-based prospective study--onset and course of Postnatal depression and developing screening system. SAMPLING AND METHOD: One hundred and one consecutive admitted women on maternity ward in our university hospital were invited to the study and 88 mothers participated. Present psychiatric status was assessed by telephone interview at three weeks and three months postnatally, using the Schedule for Affective Disorders and Schizophrenia and diagnosis was made based on Research Diagnostic Criteria. The Maternity Blues Scale and Edinburgh Postnatal Depression Scale (EPDS) were also administered at the 5th day, one and three months postnatally. RESULTS AND DISCUSSION: At 3 weeks, 21 of the 88 mothers (24%) were categorized as having had Maternity blues, and twelve (14%) were diagnosed as depression cases. At 3 months postpartum overall 15 of 88 mothers (17%) were categorized as depression cases. Ten out of total 15 mothers had their onset of depression within the first week. There were no differences in age, parity, educational level, social class compared to non-depressed mothers. The scores of the Blues and the EPDS were always significantly higher in depressed mothers. The Blues scale score was significantly higher in the depressed mothers compared to the control mothers at any timing of investigation. Even at the fifth postnatal day, 11 of 15 mothers who subsequently became clinical depression had already scored 9 or more, which is indicative of postnatal depression, this means postnatal depression could be detected from the very early postpartum period. As for the validity test of the EPDS, having set a cut-off point being 9 or more, the sensitivity was 82% and the specificity were 95% respectively. This score is the same as Okano reported in Japan and lower than many studies in Western countries. Study II Multi-centre prospective study of early postpartum mood states. SAMPLING AND METHODS: Fourteen obstetric wards in teaching hospitals participated in the study, and there, recruitment in each ward continued until 20 post-natal women had agreed to participate. Two hundred twenty six patients (89.7%) completed the study. During the first 5 days Maternity blues scale, and the EPDS on the 5th postnatal day, and one month postnatally the EPDS again were given to the mothers. The EPDS score of 9 or more was regarded as a probable case of postnatal depression. RESULTS AND DISCUSSION: Seventy-nine out of the 226 patients (35%) had maternity blues. Forty six out of the 226 patients (20%) had postnatal depression (EPDS being 9 or more) at one month postnatally. There was a significant correlation between the EPDS scores on the 5th postnatal day and those at one month. Having maternity blues and higher than 9 or more of the EPDS score were significantly related to the EPDS scores of 9 or more at one month postnatally. (odds's ratio = 4.4 and 13 respectively). Dysphoria on 5 day was significantly related to history of pregnancy loss, Caesarean section, Maternal and neonatal complications and Maternity blues. Dysphoria on one month was only related to Maternal complication. CONCLUSIONS: The onset of postnatal depression can be within the first week after delivery. The use of the EPDS during the first week is a simple and useful screening for early onset case. Maternal complications and related medical factors might be the risk factors of mood disturbance during early postnatal period.     

Obstetrical complications and the development of postpartum depressive symptoms: a prospective survey of the MATQUID cohort

Verdoux H, Sutter AL, Glatigny‐Dallay E, Minisini A. Obstetrical complications and the development of postpartum depressive symptoms: a prospective survey of the MATQUID cohort. Acta Psychiatr Scand 2002: 106: 212–219. © Blackwell Munksgaard 2002. Objective: To prospectively investigate in a cohort of pregnant women the association between obstetrical complications (OCs) and depressive symptomatology in the early postpartum period. Method: A total of 441 pregnant women attending the State Maternity Hospital in Bordeaux were interviewed during the third trimester of pregnancy, then at 3 days and 6 weeks after birth. Maternal depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS). Data on a large range of pregnancy, delivery and neonatal somatic adverse events were collected by interviewing the mothers. Data on OCs were rated using the McNeil–Sjöström scale for OCs. A dimensional definition of postnatal depression (EPDS summary score 6 weeks after delivery) was used to explore the relationships between OCs and early postnatal depressive symptoms. Results: Exposure to severe OCs during pregnancy was associated with more intense depressive symptoms in the early postnatal period, independently from demographic characteristics, marital adjustment, parity, and a history of depressive or anxiety disorder during pregnancy (adjusted B=0.16, 95% CI 0.007, 0.30, P=0.04). No association was found between the severity of postnatal depressive symptoms and labour/delivery or neonatal complications. Conclusion: Severe pregnancy complications may increase the severity of postnatal depressive symptoms by acting as acute or chronic stressors during pregnancy. The links between OCs, maternal psychopathology, and child development, need to be explored further.     

Postpartum mood disorders

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The ‘baby blues‘ are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.     

Risk factors for early postpartum depressive symptoms

OBJECTIVE: Postpartum depressive disorders are common and symptoms may appear as early as the first 2 weeks postpartum. Data regarding hormone-related risk factors for depressive symptoms occurring in the very early postpartum period are scarce and may be of importance in identifying serious postpartum illness. We examined the association between the reported history of psychiatric symptoms of possible hormonal etiology and very early postpartum depressive symptoms. METHODS: All women (n= 1,800) in a general hospital maternity ward were assessed during the first 3 days after parturition for potential risk factors for postpartum depressive disorders by a self-reported questionnaire and for present mood symptoms (Edinburgh Postnatal Depression Scale, EPDS). The associations between potential risk factors and postpartum depressive symptoms were analysed. RESULTS: The incidence of women with an EPDS >or=10 was 6.8% (88/1,286). Significant risk factors for early postpartum depressive symptoms were a history of mental illness including past postpartum depression (PPD), premenstrual dysphoric disorder (PMDD), and mood symptoms during the third trimester. CONCLUSION: In accordance with other studies, a history of depression was found to be a risk factor for early postpartum mood symptoms. An association was also found between some risk factors of possible hormone-related etiology such as PMDD and third trimester mood symptoms and early postpartum mood symptoms. As such, early postpartum symptoms may indicate vulnerability to subsequent PPD; it may be of importance to assess these risk factors and mood immediately after parturition. A prospective study is needed to determine which of these risk factors is associated with progression to PPD and which resolves as the blues.     

Detection, prevention and treatment of postpartum depression: a controlled study of 859 patients

This study evaluated the clinical effectiveness of a programme aimed at detecting, preventing and treating postpartum depression. The French version of the EPDS was used to measure the intensity of postpartum blues on a sample of 859 women, during their stay at the obstetrical clinic. Subjects under treatment for psychological problems were excluded from the study. Mothers scoring 9 or above on the EPDS, which is predictive of pospartum depression, were randomly assigned to a prevention and a control group. Written informed consent was obtained from the subjects after the study procedure had been explained. The prevention group received a counselling session integrating supportive, educational and cognitive-behavioral components. Therapists included five female Master's Degree level students in psychology. All therapists participated in didactic and clinical training as wells as weekly supervision from the first author. All subjects were given a second EPDS with written instructions to complete the questionnaire during the period 4 to 6 weeks postpartum and return it for analysis. At four to 6 weeks, women in the prevention group had significant reductions in the frequency of probable depression, as defined by a score of 11 or above on the EPDS (30.2% vs 48.2%, chi 2 = 7.36, dl = 1, p = 0.0067) and in the intensity of depressive symptoms measured by the mean score on the EPDS (8.5, SD = 4 vs 10.3, SD = 4.4, t = 3.06, dl = 209, p = 0.0024). Mothers with a probable depression were interviewed at home and assessed using the MINI (Mini Neuropsychiatric Interview, Lecrubier et al., 1997) to diagnose major depressive episode, the SIGH-D (Structured Interview Guide for the Hamilton Depression Rating Scale, Williams, 1988) and the BDI (Beck Depression Inventory, Beck et al., 1988). The baseline depression rating scores, EPDS (mean = 13.6, SD = 4), BDI (mean = 15.7, SD = 5.9), HDRS (mean = 14.8, SD = 6), were consistent with moderate depression. No significant differences in baseline scores were observed between the two groups on all the rating scales (p < 0.001). Mothers with probable depression in the prevention group were offered a program of 5 to 8 home visits. Most of the mothers in the prevention group (72%) agreed to participate in the program. On the contrary, most of the mothers (83.3%) who scored below 9 on the first EPDS and 11 or above on the second, who so did not received the preventive counselling session, declined to participate. This suggests the importance of the preventive session in establishing therapeutic alliance. The home visits program integrated four components, supportive, educational, cognitive-behavioral and psychodynamic centred on the mother-infant relationship in terms of the mother's personal history. Therapist participated in clinical training and weekly supervision. Fifteen women (71.4%) in the study group demonstrated complete symptom remission, as defined by HDRS score below 7 after the intervention, compared with 4 women (10.5%) in the control group (chi 2 = 23, p < 0.0001). A clearly therapeutic response to treatment was observed in the treated group with a mean reduction in HDRS score of 9.5 (DS = 6.7) from baseline. The improvement in the women in the treated group, as measured by the mean HDRS scores was statistically greater than that in the control group (m = 5.35, SD = 3.5 vs m = 15.8, SD = 4.6, t = 8.24, dl = 52, p < 0.0001). Our results indicate that a program based on an intervention at obstetrical clinics and on home visits is efficacious and well accepted for prevention, detection and treatment of postpartum depression.     

Time-to-remission from geriatric depression: psychosocial and clinical factors.

OBJECTIVE: The authors examined psychosocial and clinical predictors of time-to-remission in a sample of initially clinically depressed elderly patients. METHODS: Using a standardized algorithm, a prospective cohort study enrolled 239 patients undergoing treatment. Patients were followed for up to 4.5 years, until death or withdrawal from the study. Baseline predictor variables included psychosocial factors, such as four domains of social support; basic and instrumental activities of daily living; and clinical factors, including use of electroconvulsive therapy (ECT), past history of depression, comorbidities, and antidepressant treatment. RESULTS: Only 33% of the sample (n=79) met our classification for depression remission. A lack of instrumental and subjective social support, poor self-rated health, the use of antipsychotic medication, or use of an antidepressant in the last 7 days were predictors of longer time-to-remission. Use of ECT in the last year was related to shorter time-to-remission. CONCLUSION: Baseline psychosocial factors were just as important, as predictors of depression remission, as were clinical and diagnostic variables. Interventions directed toward social support resources, in addition to clinical intervention, including the use of ECT where appropriate, are likely to improve rates of depression remission.     

产后抑郁的有关心理、社会和生物学因素研究

目的调查产后抑郁的发生率以及相关的生物、心理、社会因素。方法对299名产妇在产后第3天用Edinburgh产后抑郁量表(EPDS)进行评定，并收集有关的心理社会因素以及产科因素。其中的117名完成产后第42天的EPDS评定。结果产后抑郁的发生率为23.08%，家庭支持等心理社会因素和产后抑郁密切相关。结论产后抑郁的发生具有一定的社会和心理因素。     

Sleep deprivation and the postnatal blues.

This prospective study of 63 women was designed to investigate the relationship between sleep disruption prior to the birth, during labour and in the early postpartum period and the subsequent development of the postnatal blues. The results from this preliminary study suggest that two factors: (a) a night-time labour; and (b) a history of sleep disruption in the latter stages of pregnancy, may have aetiological importance in the development of postnatal blues. There was little evidence from this study to suggest that sleep disruption on the nights following the birth, the third sleep factor investigated, had any impact on the expression of the blues.     

Factors associated with self-esteem following acquired brain injury in adults: A systematic review

Self-esteem is potentially a key factor in psychological and psychosocial well-being following acquired brain injury (ABI). The current review aimed to identify, synthesise and appraise all existing quantitative empirical studies on predictors or correlates of self-esteem following ABI in adulthood. In total, 27 papers met the inclusion criteria. A range of clinical factors were related to self-esteem after ABI, including the degree of physical and functional impairment. It is unclear if cognitive impairment is related to high or low self-esteem. Additionally, psychological variables such as coping styles, adjustment and perception of problems or rehabilitation are related to self-esteem following ABI. Depression is strongly associated with low self-esteem, alongside anxiety, psychological distress and quality of life. Limitations of the available research and recommendations for clinical practice and further research are discussed. In particular, there is a need to engage with contemporary theoretical understandings of self-esteem, integrated with and supported by developments in how self-esteem is conceptualised and measured over time in an ABI population. The findings of the review suggest that self-esteem is an important factor to consider following ABI, particularly in the context of developing individualised, formulation-driven rehabilitation interventions that take into account biological, social and psychological factors.     

Weight gain in breastfed infants of mothers taking antidepressant medications

BACKGROUND: Little is known about the physical development of infants who are exposed to antidepressant medications through breast milk. METHOD: Seventy-eight breastfeeding women taking antidepressant medications were included in the study. Maternal mood was prospectively evaluated at 6, 12, and 18 months postpartum. Infants' weights were obtained from review of pediatric records. Data were gathered from 1997 to 2002. RESULTS: Infants' weights were not significantly different from weights of 6-month-old breastfed infants from normative populations. However, infants of mothers who relapsed to relatively long-lasting major depressive episodes (lasting 2 months or more) following delivery weighed significantly (p =.002) less when compared with infants of mothers who relapsed to brief depressive episodes (< 2 months) and infants of mothers who did not relapse to depression in the postpartum period. This finding remained after including medication dosage and infant birth weight as covariates. CONCLUSION: Exposure to antidepressant medications through breast milk does not appear to affect infants' weight. However, infants exposed to maternal depression lasting 2 months or more appear to experience significantly lower weight gain than infants of euthymic mothers or mothers who experience brief (< 2 months) major depressive episodes. Maternal depression following delivery may influence behaviors that, over the course of 2 months or more, affect infants' weight gain.