Patterns of peripartum depression and anxiety during the pre-vaccine COVID-19 pandemic.

BACKGROUND: Pregnant people are vulnerable to new or worsening mental health conditions. This study aims to describe prevalence and course of depression and anxiety symptoms in pregnancy during the pre-vaccine COVID-19 pandemic. METHODS: This is a prospective cohort study of pregnant individuals with known or suspected COVID-19. Participants completed Edinburgh Postnatal Depression Scale (EPDS) and Generalized-Anxiety Disorder-7 (GAD-7) questionnaires, screening tools for depression and anxiety, at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum. Prevalence of elevated depressive and anxiety symptoms at each visit was described. Univariable logistic regression analysis was used to determine the association between demographic and clinical factors and those with elevated depression or anxiety symptoms. RESULTS: 317 participants were included. The prevalence of elevated antepartum depression symptoms was 14.6%, 10.3%, and 20.6% at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum, respectively. The rate of elevated anxiety symptoms was 15.1%, 10.0%, and 17.3% at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum, respectively. A prior history of depression and/or anxiety (p's < 0.03), as well as higher EPDS and GAD-7 scores at enrollment (p's < 0.04) associated with elevated depression and anxiety symptoms throughout pregnancy and the postpartum period. Quarantining during pregnancy was associated with elevated anxiety symptoms at 34weeks gestational age in univariate (P = 0.027) analyses. COVID-19 diagnosis and hospitalization were not associated with elevated depression or anxiety symptoms. CONCLUSIONS: Elevated depression and anxiety symptoms were prevalent throughout pregnancy and the postpartum period, particularly in those with prior depression and/or anxiety and who quarantined. Strategies that target social isolation may mitigate potential adverse consequences for pregnant people, and continued vigilance in recognition of depression and anxiety in pregnancy should be considered.

Exploring the impact of maternal early life adversity on interoceptive sensibility in pregnancy: implications for prenatal depression.

PURPOSE: Pregnancy is a sensitive period of development in adult life characterized by massive changes in physical, emotional, and cognitive function. Such changes may be adaptive, e.g., facilitating adjustment to physical demands, but they may also reflect or contribute to risks inherent to this stage of life, e.g., prenatal depression. One cognitive ability that may undergo change during pregnancy and contribute to mental wellness is interoception - the ability to perceive, integrate, and model sensory information originating from the body. Strong interoceptive abilities are associated with lower rates of depression in non-pregnant adult populations, and interoception is generally weaker in individuals at higher risk for depression, for example, exposure to early life adversity (ELA). In the present online, cross-sectional study, we investigated whether interoception in pregnant women differed based on histories of ELA, in ways that increased their relative risk for prenatal depression symptoms. METHODS: The pregnant individuals were in the second trimester of their first pregnancy and were compared to a group of nulliparous, non-parenting women. RESULTS: Previous exposure to ELA significantly moderated pregnancy-related differences in self-reported interoception (interoceptive sensibility). A further moderated-mediation analysis revealed that the extent to which interoceptive sensibility buffered against depressive symptoms was conditional on ELA exposure, suggesting more ELA is associated with lower interoceptive sensibility during pregnancy, which increased prenatal depression risk. CONCLUSIONS: Together this work suggests that levels of interoception during pregnancy are sensitive to previous adversity exposure. It also suggests that interoceptive-focused interventions for preventing/treating prenatal depressive symptoms in high-risk women may be worth exploring.

We're Not Sure We Like It but We Still Want More: Trainee and Faculty Perceptions of Remote Learning During the COVID-19 Pandemic.

OBJECTIVE: In this study, the authors aim to compare perceptions of remote learning versus in-person learning among faculty and trainees at a single institution during the COVID-19 pandemic and to evaluate the impact that a brief faculty training on best practices in online teaching would have on faculty attitudes towards remote learning. METHODS: The authors conducted an attitude survey on remote learning among trainees and faculty members approximately 3 months after the transition from in-person to remote learning. The authors then conducted a faculty training on best practices in online teaching followed by an evaluation survey. Study findings were examined descriptively and by Fisher's exact testing. RESULTS: The response rates for the attitudes survey were 68% among trainees and 61% among faculty. Trainees and faculty perceived in-person learning more favorably than remote learning across a variety of domains, including overall enjoyment, interpersonal connection, ability to communicate, and concentration. Despite these trends, only 10% of trainees and 14% of faculty felt that all lectures would be most effectively delivered in-person when this becomes possible again. The response rate for the faculty training evaluation survey was 16%. Compared to non-attendees, faculty attendees reported more confidence in their ability to teach remotely (89% vs 56%, p=0.02) but not increased optimism (89% vs 63%, p=0.06). CONCLUSIONS: The study findings suggest that both trainees and faculty perceive remote learning negatively compared to in-person learning but still feel that some lectures should be delivered remotely even after a return to in-person learning is possible.

What's in a Name? From Book Forum to Media Forum.

As editors of the Book Forum, we have seen an increased interest in authors writing reviews in other media sources besides books. This is not a surprise as we find more media sources that we go to for information as well as entertainment. On top of that, for better or worse, our patients are spending more of their time on other sources of media besides books. We are often unfamiliar with these media sources and are unable to engage meaningfully with our patients. This can be important in rapport building, which was a consideration when we had people review, for example, the video games Fortnite and Among Us. It can also be important in understanding the safety concerns of a media source, preparing our readership of child and adolescent psychiatrists to talk about controversial, potentially triggering topics with patients (ie, Thirteen Reasons Why). The goal of the Book Forum has always been to introduce child and adolescent psychiatrists to materials that would be important for their education or enjoyment and to understand the materials that our patients may be perusing. In an effort to continue this mission, we worked with Journal staff to rebrand the Book Forum as the Media Forum. We hope that this move will only add to the opportunities you all have as writers and readers, as we still welcome books, but now we welcome movies, TV shows, short videos, articles, video games, and anything else you think would be relevant. As you can see from this month's reviews of books, we continue to encourage reading and the submission of book reviews. We look forward to your suggestions for future reviews.

Seeking Meaning in the Void.

One of the most important jobs in elementary school can be distilled down to 2 words: line leader. This is the mighty carrot to mobilize ordinarily sluggish children through their morning routine, as they look forward to standing proudly at the front of their classroom line. I have witnessed this phenomenon myself, as my first-grade son was chosen to be the glorious line leader of room 15. He moved with a sense of urgency in the morning to pack his backpack, fill his water bottle, and put on his shoes and socks, all with zero parental prompting. After I dropped him off, I secretly watched through the chain-link fence as he skipped over to his class with his head held high to claim his hard-earned position as the Tuesday line leader. The look of pride on his face was undeniable. This leadership position truly meant something to him, giving him a sense of purpose. As he marched his class to the same classroom door that they walk through every day, it was clear that the kid walking through the door had a little more shine than he had the day before.

The Developing Child.

As children age, there are set milestones that we follow clinically to help track fine motor, gross motor, social, and language development. Because we know what a 2-month-old vs 4-month-old vs 1-year-old child should be able to do, we are able to assess whether a given child is on track developmentally. In pediatrics, three developmental stages are assessed and, if, behind there is a clear next step, often to involve early intervention. In child psychiatry, work has been done to establish stages of development as well, seen through the work of Piaget, Erickson, and others. These stages help to define the thoughts and behaviors expected for different-aged children, and thus can help with putting together our diagnostic formulation. The difficulty is that these stages are much broader temporally then the early motor, social, and language developmental milestones. Students may also be participating in the same experiences, such as the same grade level, even though they are at different developmental levels based on their age when they started school, as there could be as much as a year difference between those in a given grade. This has led to concerns about being able to distinguish a child struggling with attention-deficit/hyperactivity disorder (ADHD) relative to a child who is younger than his peers, as teachers may compare a young child to their older peers when filling out assessment forms.1 These are the developmental questions that we often must ponder as child psychiatrists, inasmuch as mental health and behavioral development are complex and influenced by many factors. In this month's Book Forum, Rishab Chawla looks more into these questions in the review of Nasty, Brutish and Short by Scott Hershovitz, pointing out that there is an overlap between the skills of a child psychiatrist to assess the behavioral impact of these developmental questions and the philosophical questions that younger children start to ponder. The child's developmental understanding of right and wrong will better help us to assess the behaviors that present to us in the office. As Rishab points out in the review, we must ask more about these children whom we see regarding these philosophical questions to better understand some of the behaviors present. Looking more deeply into a student's understanding of these questions may better help us to distinguish developmentally appropriate or inappropriate behaviors.

The Power of Shared Experience.

The experiences of others can often be used as a motivator, caution tale, point of education, and much more. Parents describe their own experiences to help their children make the right choices, including avoiding some mistakes they might regret. We watch movies and read books about historical figures, actors, athletes, and other famous people to better understand how their experiences shaped the person they became. More recently the growth of influencer culture has led people to watch videos to make decisions based on what the person tells them of their own experience. The difficulty is that many of these experiences have been selectively crafted to fit what makes a good movie or to promote a product.

What Makes Us Who We Are?

As child and adolescent psychiatrists, it is our job to identify factors that influence the behaviors seen in front of us. Often the question is asked whether these factors are primarily due to nature or nurture: Is someone born a "bad kid," or are there environmental exposures that lead to less than ideal behaviors? Factors such as racism, poverty, bullying, social isolation, and even where we grow up could play a part in the behaviors seen. This is one of the most rewarding, but at times can be one of the most frustrating, parts of our job as child and adolescent psychiatrists. Hopefully we can explore the factors influencing behaviors seen by the children we work with, highlighting the good in them and the situations that have led to the concerns seen. At the same time, we can become frustrated knowing that some of these factors are difficult for us to change as an individual child and adolescent psychiatrist, such as racism, poverty, inequalities in education, or family support. Bearing witness to these societal issues and their impact on our patients hopefully sparks advocacy efforts toward larger system changes.

The Cost of Avoidance.

As child psychiatrists, it is our job to ask questions, and many of us would say we are really good at it. We work with our patients to open up about their experiences, discussing fear, sadness, hope, and joy. By modeling this ability to open up in the office, we help guide children and adolescents through using other skills rather than avoidance. Although avoidance has its place at times, we help show our patients the connection between anxiety and avoidance. This necessity to embrace and challenge fears can be a difficult skill for our patients and also their families. Children bring forward questions that parents may want to avoid, fearing the answer might be more difficult for the child than the rejection of having the question avoided all together. As someone who works with children with chronic illnesses, this avoidance of the question can in fact increase the fear and anxiety of the child or adolescent. When talking to children, often they will express a greater fear than the reality of the situation because they determine that if their parent is avoiding the question, it must be really bad. This same struggle with avoidance can be true for us as child psychiatrists as well. The necessity to take on roles of leadership or run a team often presents itself, but excuses can come up to help us avoid these roles. We might say we are not properly trained, we did not go into medicine to do those responsibilities, or we are too busy. By avoiding these responsibilities, we are setting ourselves up for more frustration. As teams struggle, we have to follow the lead of others without the same clinical knowledge, which may result in additional errors. We must remember to practice what we preach and to identify the cost of avoidance.

Rupture and Repair.

Rupture and repair are key ingredients to connection. When ruptures in relationships occur, which they will, it is important to revisit the situation to work on restoring safety, regulation, attunement, and understanding. Through engaging in this process and providing consistent secure base and safe haven supports, conflicts have the opportunity to heal. Developmentally, the practice of rupture and repair begins during infancy and early childhood, laying the foundation for secure attachment. What happens when ruptures repeatedly occur without repair? How does this impact self-esteem and the narratives children create about themselves as they grow? As you can imagine, repeated rupture without repair can lead to mistrust, cognitive distortions, resentment, and emotional stunting. As child and adolescent psychiatrists, we can help families understand that relationships, like people, can bend without breaking-and that a healthy serving of humble pie can be just what the doctor ordered.

Protecting Sense of Self.

Not too long ago, I took my family to see the Pixar movie Inside Out 2 in the theater. My children sat down according to their developmental age, with my oldest farthest away and my youngest right by my side. I watched as their faces lit up during various scenes, wondering if they were connecting to an emotional epicenter in their brain or perhaps reflecting on their own core memories and beliefs. In all likelihood, they were probably appreciating the incredible graphics or booming surround sound, although-as we all know-children are beautifully complex beings. In this movie, the concept of sense of self is introduced, represented by magical strings (ie, beliefs) that come together to form a glowing, almost celestial, orb. Toward the end of the movie, in an intense and critical scene, many of the emotions are gathered around the orb, or sense of self, trying to rescue the main character (ie, Riley) from herself. It is one of those scenes in which every muscle in your body is flexed and you feel the entire emotional gravity of a situation. I looked over at my 5-year-old daughter, who had her eyes closed tight, her little jaw clenched, and her arms fully extended in front of her, hugging an imaginary sense of self orb. She stayed in this posture long enough for the audience to let out an audible "Awwww," albeit not long enough for me to snap an actual picture. I saw a tear stream down her face as she protected Riley's sense of self with all her might, and may have given her a few extra gummy bears to reward her investment.

Finding the Time to Reconnect.

Starting in March 2020, we went into a period of collective social isolation that seemed like it would never end. As we mostly stayed in our own spaces, seeing others only by screens or through a distance, we at times lost connections. As we continue to move back to reconnecting and rebuilding our social networks, it represents a time to reflect back on what happened before. We can see the impact that this isolation had on mental health and our ability to reconnect with others post pandemic. Of course, the hope is that going through a pandemic such as this is not something any of us will experience again in our lifetime. That being said, periods of isolation will most likely happen to us again at some point in our lives. It leads to the point of us wondering: how could we do better, and how could we better keep these connections even when physically we are isolated? Although a lot of effort will be poured into how to prevent another infectious disease pandemic, we must not forget the topic of how to avoid another mental health pandemic.

Lessons Learned From Magna-Tiles.

Have you ever built a spaceship using Magna-Tiles with a 4-year-old child? If not, place this on the top of your to-do list, as there are many lessons hidden within these colorful pieces of plastic. In addition to teaching patience and cooperation, the process of building with a preschooler with big emotions and an underdeveloped prefrontal cortex offers endless opportunities to serve as both a safe haven and a secure base. As each tile is carefully (or not so carefully) placed, you are building more than just a misshapen spaceship; you are reinforcing a foundation of trust and mutual respect. In helping my own 4-year-old daughter build a unicorn-themed spaceship that resembled a tug boat, I cringed when she placed the final tile that would collapse our creative masterpiece. Much to my surprise, instead of disappointment and tears, she erupted into laughter and began the process of building all over again. She reminded me that joy can come from an experience rather than an outcome, that creativity and imagination should be sprinkled daily into the work we do, and that not every spaceship is destined to be out of this world!

Remodeling Broken Systems: Addressing the National Emergency in Child and Adolescent Mental Health.

A national emergency in child and adolescent mental health was declared in the United States in 2021 in the wake of the COVID-19 pandemic. This Open Forum discusses potential solutions to better support child and adolescent mental health by improving or expanding school-based mental health services, child psychiatry access programs, virtual mental health services, and new models of care (e.g., integrated youth services hubs and crisis stabilization units). The success of such programs is dependent on stable funding, strong leadership and accountability, robust and well-trained workforces, systems integration, and attention to health equity.

The Impact of Postpartum Depression on the Early Mother-Infant Relationship during the COVID-19 Pandemic: Perception versus Reality.

Postpartum depression (PPD) can interfere with the establishment of affective bonds between infant and mother, which is important for the cognitive, social-emotional, and physical development of the child. Rates of PPD have increased during the COVID-19 pandemic, likely due to the added stress and limited support available to new parents. The present study examined whether parenting-related stress, perceived bonding impairments, the quality of observed mother-infant interactions, and salivary oxytocin levels differ between depressed and non-depressed mothers, along with differential impacts of COVID-19 on depressed mothers. Participants included 70 mothers (45 depressed, 25 controls) with infants aged 2-6 months. All data were collected remotely to ease participant burden during the pandemic. Depression was associated with experiences of heightened parenting-related stress and bonding difficulties. These differences were not observed during mother-infant interactions or in salivary oxytocin levels. Differences in COVID-19-related experiences were minimal, though depressed mothers rated slightly higher stress associated with returning to work and financial impacts of the pandemic. Findings highlight the importance of early intervention for PPD to mitigate long-term effects on mothers, children, and families. Additionally, they underscore the need for early intervention to support the developing mother-infant dyad relationship during this crucial time.

Study protocol: perinatal mood treatment study.

Perinatal depression (PND) affects up to 20% of women and is associated with significant impairment and disability in affected women. In addition, perinatal depression is associated with broader public health and multigenerational consequences. Innovative approaches are needed to reduce the burden of perinatal depression through identification, tracking, and treatment of depressive symptoms during the perinatal period. This study is a randomized clinical trial comparing the relative efficacy of a multi-tiered system of care, Screening and Treatment of Anxiety and Depression (STAND) to perinatal care delivered by a reproductive psychiatrist in reducing symptoms of depression and anxiety. A sample of 167 individuals was randomized between week 28 of pregnancy and 6 months postpartum. A secondary aim compares the original online therapy intervention used in the first half of the study to a newer online therapy program used in the second half of the study for individuals assigned to the STAND treatment. The study measures, intervention groups, and analysis methods are described, as well as expected implications. The findings from this study may improve the methods for tracking symptom changes over time, monitoring treatment response, and providing personalized care for individuals with PND. As such, this study may improve the lives of patients with PND and their families and lower the related health care costs to society.Trial registration NCT: 9/24/2021NCT direct link: https://www.clinicaltrials.gov/study/NCT05056454?term=NCT05056454&rank=1&a=1 .

Peek-A-Boo, I See You!

Peek-A-Boo is a beloved game played around the world, crossing language and cultural barriers alike. In addition to reinforcing the magical principle of object permanence, Peek-A-Boo generates laughter and shared joy that is contagious. While engaging with a patient diagnosed with postpartum depression, I was delighted to witness the power of this game on full display. When her 10-month-old son grew fussy as she discussed her matrescence, the patient gave me a playful look before abruptly covering her eyes with both hands. She waited a moment, then quickly uncovered her eyes while squealing "Peek-A-Boo, I see you!" I can still hear his gasp of surprise followed by a hearty, deeply committed belly laugh that echoed in the room. Why is this game so universally loved? Is it because it promotes connection, can be used as a powerful learning tool, or perhaps because it reinforces the idea that things stick around even when you can't see them? Maybe it is all of these things swirling together at once, built on a deeper principle that feeling seen and accepted without condition feels pretty darn good. Either way, I walked away from that encounter reminded of the simple truth that laughter-especially from a spirited baby-can be the best medicine.

Adventures in Fortnite: Selections From Connect Corner.

JAACAP Connect, our developmental journal, began publishing in 2014 to support "the development of writing and editing skills among members of the American Academy of Child and Adolescent Psychiatry." JAACAP Connect "is dedicated to engaging trainees and practitioners in the process of continuous and applied career learning through readership, authorship, and publication experiences that emphasize translation of research findings into the day-to-day clinical practice of child and adolescent psychiatry." Over the past 8 years, dozens of new or early career authors have worked closely with JAACAP Connect editors to develop manuscripts into published articles.