Examination of premenstrual symptoms as a risk factor for depression in postpartum women

Postpartum depression (PPD) is a significant public health concern with prevalence of major and minor depressions reaching 20 % in the first three postpartum months. Sociodemographic and psychopathology correlates of PPD are well established; however, information on the relationship between premenstrual disorders and the development of PPD is less well established. Thus, the aim of this study was to examine the role of premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) as a risk factor for PPD. Premenstrual symptoms were assessed retrospectively using the premenstrual symptoms screening tool (PSST) and depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria and assessed using the Hamilton Depression Rating Scale (HDRS). A two-stage screening procedure was applied. In the first stage, the Patient Health Questionnaire (PHQ-9) was employed. In the second stage, women endorsing ≥5 symptoms on the PHQ-9 were administered the Structured Clinical Interview for DSM-IV, HDRS, and PSST. Hierarchical linear regression showed that history of depression and PMS/PMDD contributed an additional 2 % of the variance (p?<?0.001), beyond that of sociodemographic factor effects. The full model accounted for 13 % of the variance in postpartum depressive symptoms. Using logistic regression, a significant association also emerged between PMS/PMDD and PPD (OR?=?1.97). The findings of this study suggest that PMS/PMDD is an important risk factor for PPD. Women endorsing a history of PMS/PMDD should be monitored during the perinatal period.     

Randomized controlled trial assessing the effect of vitamin A supplementation on maternal morbidity during pregnancy and postpartum among HIV-infected women

OBJECTIVE: To determine whether low-cost treatment of HIV using vitamin A would be beneficial, we examined the effect of vitamin A supplementation on morbidity of HIV-1 infected women. METHODS: We conducted a randomized, double blind placebo-controlled trial at King Edward VIII Hospital, in Durban, South Africa. In total, 312 HIV-seropositive pregnant women between 28 and 32 weeks' gestation were recruited into this trial. Patients were randomized to receive placebo or 5,000 IU retinyl palmitate and 30 mg beta-carotene daily. At delivery of their children, patients received placebo or 200,000 IU retinyl palmitate. The main outcome measures were pre- and postnatal report of HIV-related symptoms. RESULTS: Vitamin A did not confer any significant beneficial effect on the report of either HIV or pregnancy-related symptoms during the pre- or postnatal period. CONCLUSION: In this study of HIV-infected pregnant women, vitamin A supplementation given in doses designed to decrease mother-to-infant transmission did not result in significant beneficial effect on reported symptoms pre- or postnatally. Further investigation with larger number of participants, tailoring supplementation for specific clinical conditions, outside the context of pregnancy, is required to help clarify the possible clinical benefits of vitamin A.     

The validity of DSM symptoms for depression and anxiety disorders during pregnancy

Background

The applicability of the symptom criteria for diagnostic mood and anxiety disorders has in recent times been questioned for women in the perinatal period, due to the overlap of diagnostic symptoms with normal symptoms due to the physical changes of pregnancy or postpartum, (e.g., sleep difficulties).

Method

118 women in their second or early third trimester of pregnancy participated in a telephone interview that included the depression and anxiety modules of the MINI diagnostic interview, and an attributional probe question asking the woman whether endorsement of a symptom was due to the physical changes of her pregnancy or due to her mood or worries.

Results

66% of pregnant women who met criteria for major depression reported that a sufficient number of their symptoms were due to the normal physical changes of their pregnancy, such that they would no longer meet criteria for a diagnosis of major depression. Attributional probing resulted in the rate of major depression falling from 6.8% to 1.7%. The impact on anxiety disorders appears to be less.

Limitations

An important issue is whether women's attributional perceptions are valid, though the face validity of some of their responses means that credence should be given to the findings. In addition, it would be useful from a validity perspective to undertake the same attributional probing with other populations where symptom presence is most likely due to mood, such as unemployed or recently separated adults without physical complaints.

Conclusion

Rates of depressive disorders in pregnancy, using DSM symptom criteria, are significantly over-estimated due to the natural occurrence of many of the symptoms as a result of the pregnancy. Rates of anxiety disorders are also inflated, but to a lesser degree. This means that the validation of self-report mood measures, typically done against DSM diagnoses, is likely to have produced erroneous findings (e.g., optimum cut-off scores). It is probable that a similar finding would be obtained for the postpartum period. Thus future use of DSM symptom criteria for depression and anxiety in perinatal mental health work should use some form of attributional probing question to more accurately understand the applicability of symptoms to a diagnosis in this population.     

Prevalence of suboptimal vitamin D status during pregnancy

Low maternal vitamin D status has been associated with reduced intrauterine long bone growth and shorter gestation, decreased birth weight, as well as reduced childhood bone-mineral accrual. Despite data from other countries indicating low maternal vitamin D status is common during pregnancy, there is a dearth of information about vitamin D status during pregnancy in the Irish female population. Therefore, we prospectively assessed vitamin D nutritive status and the prevalence of suboptimal vitamin D status in a cohort of Irish pregnant women. The mean (SD) daily intake of vitamin D by the group of pregnant women was 3.6 (1.9) microg/day. None of the women achieved the recommended daily vitamin D intake value for Irish pregnant women (10 microg/day). Taking all three trimesters collectively, 14.3-23.7% and 34.3-52.6% of Irish women had vitamin D deficiency (serum 25 (OH) D <25 nmol/l) and insufficiency (serum 25 (OH) D 25-50 nmol/l), respectively during pregnancy. Both the levels of serum 25 (OH) D and the prevalence of vitamin D deficiency/adequacy were dramatically influenced by season, with status being lowest during the extended winter period and best during the extended summer period. These findings show that inadequate vitamin D status is common in Irish pregnant women.     

The relationship between maternal attitudes and symptoms of depression and anxiety among pregnant and postpartum first-time mothers

Two studies examined the relationship between maternal attitudes and symptoms of depression and anxiety during pregnancy and the early postpartum period. In the first study, a measure of maternal attitudes, the Attitudes Toward Motherhood Scale (AToM), was developed and validated in a sample of first-time mothers. The AToM was found to have good internal reliability and convergent validity with cognitive biases and an existing measure of maternal attitudes. Exploratory and confirmatory factor analyses determined that the measure comprises three correlated factors: beliefs about others’ judgments, beliefs about maternal responsibility, and maternal role idealization. In the second study, we used the AToM to assess the relationship between maternal attitudes and other psychological variables. The factor structure of the measure was confirmed. Maternal attitudes predicted symptoms of depression and anxiety, and these attitudes had incremental predictive validity over general cognitive biases and interpersonal risk factors. Overall, the results of these studies suggest that maternal attitudes are related to psychological distress among first-time mothers during the transition to parenthood and may provide a useful means of identifying women who may benefit from intervention during the perinatal period.     

Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome

BACKGROUND: The goal was to study the effects of social support during pregnancy on maternal depressive symptoms, quality of life and pregnancy outcomes. METHODS: Eight hundred ninety-six women were prospectively studied in the first trimester of pregnancy and following completion of the pregnancy. The sample was divided into quartiles yielding groups of low, medium and high social support based on perceived social support. RESULTS: Pregnant women with low support reported increased depressive symptoms and reduced quality of life. The effects of social support on pregnancy outcomes were particularly pronounced in women who had smoked during pregnancy, with significant main effects of social support in a two-way analysis of variance (smoking status and social support) for child body length (F = 4.26, P = 0.04; 50.43 +/- 2.81 cm with low support versus 51.76 +/- 2.31 cm with high support) and birthweight (F = 11.35, P = 0.001; 3175 +/- 453 g with low support versus 3571 +/- 409 g with high support). In smokers, pregnancy complications occurred more frequently when given low support {34 versus 10.3% with high support, chi(2) = 5.49, P = 0.019; relative risk (RR) = 3.3 [95% confidence interval (95% CI) = 1.1-10.2]}, and the proportion of preterm deliveries was greater given low support (10.0 versus 0% with high support, chi(2) = 3.84, P = 0.05, odds ratio = 8.1). CONCLUSIONS: Lack of social support constitutes an important risk factor for maternal well-being during pregnancy and has adverse effects on pregnancy outcomes.     

Oxytocin course over pregnancy and postpartum period and the association with postpartum depressive symptoms

During the postpartum period, women are at higher risk of developing a mental disorder such as postpartum depression (PPD), a disorder that associates with mother–infant bonding and child development. Oxytocin is considered to play a key role in mother–infant bonding and social interactions and altered oxytocin plasma concentrations were found to be associated with PPD. In the present study, we evaluated oxytocin plasma levels and depressive symptoms during pregnancy and the postpartum period in healthy women. We evaluated 100 women twice during pregnancy (weeks 35 and 38) and three times in the postpartum period (within 2 days and 7 weeks and 6 months after delivery) by measuring oxytocin plasma levels with enzyme-linked immunosorbent assay (ELISA) and assessing depressive symptoms with the Montgomery-Asberg Depression Rating Scale. Oxytocin plasma levels significantly increased from the 35th week of gestation to 6 months postpartum in all women. However, levels decreased from the 38th week of gestation to 2 days after delivery in participants with postpartum depressive symptoms, whereas they continuously increased in the group without postpartum depressive symptoms; the difference between the course of oxytocin levels in the two groups was significant (Δt2–t3: t?=?2.14; p?=?0.036*). Previous depressive episodes and breastfeeding problems predicted postpartum depressive symptoms. Our results indicate that alterations in the oxytocin system during pregnancy might be specific for women who develop postpartum depressive symptoms. Future studies should investigate whether oxytocin plasma levels might have predictive value in women at high risk for PPD.     

Prevalence of stressful life events during pregnancy and its association with postpartum depressive symptoms

Archives of Women's Mental Health - Experiencing stressful life events (SLEs) has negative consequences for both mother and infant. This study examined the predictive contributions of (1)...     

Body mass index, eating attitudes, and symptoms of depression and anxiety in pregnancy and the postpartum period

OBJECTIVE: This report describes associations between body mass index (BMI; kg/m2), eating attitudes, and affective symptoms across pregnancy and the postpartum period in a sample of 64 women. METHODS: As part of a larger study, women were recruited during pregnancy and followed prospectively to 14 months postpartum. Measures included self-reported prepregnancy and 4-month postpartum BMI as well as pregnancy, 4-month, and 14-month postpartum eating attitudes (EAT), depressive symptoms (CES-D), and anxiety symptoms (STAI). RESULTS: During pregnancy, symptoms of depression or anxiety were not significantly correlated with concurrent eating attitudes or measures of BMI. However, at 14 months postpartum, measures of eating attitudes and both depression and anxiety symptoms were associated. Measures of BMI were associated with depressive and anxiety symptoms at both 4 and 14 months postpartum. Four-month eating attitudes and BMI predicted 14-month postpartum depressive symptoms, beyond pregnancy, and 4-month postpartum measures of affective symptoms. Results suggested that overweight women were at risk for elevated anxiety at 4 months and depressive symptoms at both 4 and 14 months postpartum. CONCLUSIONS: These results provide evidence for a significant, albeit moderate, relationship between BMI, eating attitudes, and symptoms of depression and anxiety in the postpartum period that are not present during pregnancy.     

Screening for bipolar disorder during pregnancy and the postpartum period

Bipolar disorder is a significant mental health problem among perinatal women; however, little attention has been devoted to methods of screening for bipolar disorder during this phase of women’s life cycle. There is a need for reliable and valid screening instruments for perinatal women. This paper presents a review of 11 self-report measures used to screen bipolar disorder in the general population and discusses their applicability to screening among perinatal women. Published psychometric data, including reliability, sensitivity, specificity, and positive predictive value of each self-report instrument, is presented and critiqued. We make recommendations for screening in clinical practice and highlights priorities for future research. The need for more research in this area is emphasized.     

Consequences of maternal psychological stress during pregnancy for the risk of asthma in the offspring

Asthma is a common lung condition that makes breathing difficult through the inflammation and constriction of the lung airways. Epidemiological evidence supports the presence of a positive association between prenatal maternal psychological stress (PMPS) and asthma in the offspring, suggesting the disease may have developmental origins. T‐helper 2 (Th2) cells are a major subtype of T‐helper cells, producing Th2 cytokines, which may be the main drivers of asthma symptoms. A Th2 dominant blood cytokine profile may therefore indicate an increased risk of asthma, as studies have shown a link between PMPS and a T‐helper 2 (Th2) cytokine profile in offspring. The mechanism by which PMPS may cause Th2 cytokine dominance in the offspring is unclear. Epigenetic modifications in utero can lead to long‐lasting effects that persist postnatally and have therefore been implicated in this relationship. Increased maternal blood cortisol levels due to PMPS may increase transfer of cortisol to the foetus, where the temporarily increased levels may induce changes in the epigenome. Evidence from animal studies suggests that genes controlling cytokine production in T cells can be epigenetically modified in a way that increases Th2 cytokine production. Other evidence suggests that methylation of the NR3C1 gene decreases hippocampal glucocorticoid receptor expression, leading to decreased negative regulation of the hypothalamus‐pituitary‐adrenal axis. This can increase cortisol production which has been shown to increase Th2 cytokine production. Therefore, the link between PMPS and a Th2 offspring cytokine profile, mediated through epigenetic changes, may explain the positive relationship between PMPS and asthma in the offspring.     

Prevalence of suicidality during pregnancy and the postpartum

Summary This review examined the available prevalence estimates of suicidality (suicide deaths, attempts, and ideation including thoughts of self harm) in pregnancy and the postpartum. Studies that used defined community or clinic samples were identified through multiple electronic databases and contacts with primary authors. Definitions of and measurement of suicide deaths, intentional self-harming behavior, suicide attempts, and thoughts of death and self-harm were varied and are described with each study. While suicide deaths and attempts are lower during pregnancy and the postpartum than in the general population of women, when deaths do occur, suicides account for up to 20% of postpartum deaths. Self-harm ideation is more common than attempts or deaths, with thoughts of self-harm during pregnancy and the postpartum ranging from 5 to 14%. The risk for suicidality is significantly elevated among depressed women during the perinatal period, and suicide has been found to be the second or leading cause of death in this depressed population.     

Structure of depressive symptoms in pregnancy and the postpartum period.

BACKGROUND: The present study investigated the structure of depressive symptoms in the perinatal period. METHOD: The Zung Self-Rating Depression Scale (SDS) was administered to a total of 1329 women in early, middle and late pregnancy and 5 days, 1 month, 6 months, 12 months and 18 months after the delivery. RESULTS: A number of somatic items and the suicidal ideation item of the SDS made low contributions to the evaluation of the severity of depression, and as a consequence these were excluded in the principal component analysis. Three factors were interpretable as "Cognitive", "Affective insomnia" and "Attentional" emerged at all eight assessment points. The goodness-of-fit index (GFI) generated by confirmatory factor analyses (LISREL 7.20) proved sufficiently high on all eight occasions. LIMITATION: The present study investigated only one self-rating scale and the sample comprised Japanese mothers only. CONCLUSION: The three-factor model of the SDS in the perinatal period was derived from exploratory and confirmatory factor analyses. It is noteworthy that the same three-factor structure emerged at all eight collection points in the present study.