Creating a Multisite Perinatal Psychiatry Databank: Purpose and Development.

Mental health issues during the perinatal period are common; up to 29% of pregnant and 15% of postpartum women meet psychiatric diagnostic criteria. Despite its ubiquity, little is known about the longitudinal trajectories of perinatal psychiatric illness. This paper describes a collaboration among six perinatal mental health services in Quebec, Canada, to create an electronic databank that captures longitudinal patient data over the course of the perinatal period. The collaborating sites met to identify research interests and to select a standardized set of variables to be collected during clinical appointments. Procedures were implemented for creating a databank that serves both research and clinical purposes. The resulting databank allows pregnant and postpartum patients to complete self-report questionnaires on medical and psychosocial variables during their intake appointment in conjunction with their clinicians who fill in relevant medical information. All participants are followed until 6 months postpartum. The databank represents an opportunity to examine illness trajectories and to study rare mental disorders and the relationship between biological and psychosocial variables.

Disordered sleep is related to delusional ideation and depression during the perinatal period.

OBJECTIVES: This study investigates the associations between sleep disturbances, delusional ideation (DI), and depressive symptomatology across the perinatal period. METHODS: A community sample of 316 mothers completed the Sleep Symptom Checklist, Peters Delusional Inventory, and Edinburgh Postnatal Depression Scale at three time points: second trimester of pregnancy (12-14 weeks gestation), third trimester (32-34 weeks gestation), and two months postpartum. RESULTS: Longitudinal path analysis revealed a bidirectional relationship between sleep disturbance and DI across pregnancy. Sleep disturbances in early pregnancy directly predicted symptoms of depression in late pregnancy and had an indirect effect on postpartum depression through DI in late pregnancy. CONCLUSIONS: Our results suggest that disturbed sleep during pregnancy plays a role in increased levels of DI and depressive symptoms during pregnancy and postpartum.

The interaction between oxytocin receptor gene methylation and maternal behavior on children's early theory of mind abilities.

Theory of mind, the ability to represent the mental states of others, is an important social cognitive process, which contributes to the development of social competence. Recent research suggests that interactions between gene and environmental factors, such as oxytocin receptor gene (OXTR) polymorphisms and maternal parenting behavior, may underlie individual differences in children's theory of mind. However, the potential influence of DNA methylation of OXTR remains unclear. The current study investigated the roles of OXTR methylation, maternal behavior, and their statistical interaction on toddlers' early emerging theory of mind abilities. Participants included a community sample of 189 dyads of mothers and their 2- to 3-year-old children, whose salivary DNA was analyzed. Results indicated that more maternal structuring behavior was associated with better performance, on a battery of three theory of mind tasks, while higher OXTR methylation within exon 3 was associated with poorer performance. A significant interaction also emerged, such that OXTR methylation was related to theory of mind among children whose mothers displayed less structuring, when controlling for children's age, sex, ethnicity, number of child-aged siblings, verbal ability, and maternal education. Maternal structuring behavior may buffer the potential negative impact of hypermethylation on OXTR gene expression and function.

Maternal oxytocin predicts relationship survival during the perinatal transition period: Preliminary evidence.

It is well-known that the neuropeptide oxytocin plays a critical role regulating the formation of adult-adult pairbonds in non-human animals, and recent work suggests oxytocin may similarly play an important role in romantic bonding in humans. Specifically, endogenous oxytocin is predictive of a host of relationship-enhancing behaviors, relationship quality, and even relationship survival amongst newly dating couples. This work suggests that oxytocin can buffer romantic relationships, possibly during especially difficult transition periods. One challenge that many couples face is the birth of a child: a joyous event, but one that is recognized as a major life stressor nonetheless. We aimed to investigate whether maternal oxytocin buffers the parent-partner relationship during the perinatal transition period. To test this, we analyzed data from a longitudinal study of child-bearing women (N = 269) in which endogenous oxytocin was measured in blood plasma during the 1st and 3rd trimesters and at 7-9 weeks postpartum; relationship status was assessed at the outset and 2.5 years postpartum. As predicted, lower maternal oxytocin was associated with greater risk for relationship dissolution by the time the child was a toddler (p < .05). These findings directly replicate research showing that endogenous oxytocin predicts relationship survival in dating couples, but in a novel interpersonal context. That said, only a very small number (N = 7) of couples separated; this, of course, is unsurprising given that the perinatal transition period is not a time when couples typically choose to terminate their relationship. Nonetheless, these findings must be considered preliminary until replicated in future research.

The healthy migrant effect and predictors of perinatal depression.

PROBLEM: Although prenatal depression is a risk factor for postpartum depression, current screening tools for prenatal depression fail to predict postpartum depression in some marginalized populations. BACKGROUND: The assessment of other risk factors along with prenatal depression may be needed to improve prediction of postpartum depression and these risk factors may be specific to immigrants. AIMS: We investigated the predictive utility of several measures in relation to postpartum depressive symptoms in: recent immigrants, less recent immigrants and Canadian-born women. METHODS: Measures pertaining to psychosocial risk factors, generalized anxiety, perinatal somatic and depressive symptoms were administered. Data were collected at 4 time-points: 12-14 weeks and 24-28 weeks gestation as well as 1-week and 8-weeks postpartum. Perinatal factors were entered into 3 different regression models to predict postpartum depressive symptoms at the last time-point. FINDINGS: Canadian-born women reported significantly more psychosocial risk factors compared to immigrant women. The best predictors of postpartum depressive symptoms at 8-weeks among Canadian-born women included psychosocial risk, prenatal anxiety and depressive symptoms as well as early postpartum depressive symptoms. Prenatal somatic symptoms predicted postpartum depressive symptoms among recent immigrants. Depressive symptoms at 1-week postpartum and the lack of an emotionally supportive partner were significant predictors of postpartum depressive symptoms for both Canadian-born and immigrant women. DISCUSSION: There appears to be both overlapping and distinct predictors of postpartum depressive symptoms for immigrant and Canadian-born women. CONCLUSION: The findings from this research will help guide routine screening options and patient-centered approaches to management of perinatal depression for diverse populations.

Theory of mind as a link between oxytocin and maternal behavior.

BACKGROUND: Oxytocin is a neuropeptide associated with maternal behavior. However the mechanisms underlying this link remain unclear. In a previous study we observed an indirect effect of increased plasma oxytocin during late pregnancy on early postpartum maternal interactive behavior via theory of mind, as assessed by the Reading the Mind in the Eyes Test (RMET). The current study aimed to extend these findings by testing whether this indirect effect would hold longitudinally for maternal behavior at 2-3 years postpartum, as well as for an additional observational measure of maternal mind-mindedness. METHOD: The original sample of 316 pregnant women (Mage = 31.92 years) was assessed at 12-14 weeks gestation (T1), 32-34 weeks gestation (T2), and 7-9 weeks postpartum (T3). Follow-up measures were taken at 2-3 years postpartum (T4). RESULTS: Mothers' RMET performance (T3) was associated with more structuring and less intrusive maternal behavior at 2-3 years (T4), while their tendency to use mind-related comments (T3) was associated with greater sensitivity (T4). Bootstrap estimates also revealed a significant indirect effect of plasma oxytocin levels during late pregnancy (T2) on maternal structuring and non-intrusive behavior at 2-3 years postpartum (T4) through RMET performance (T3). CONCLUSIONS: Results: of the current study confirm and extend the previous findings, demonstrating that theory of mind may represent a social cognitive mechanism linking endogenous oxytocin and maternal behavior. Important changes in the oxytocinergic system during late pregnancy may help prepare for motherhood by promoting the awareness of social cues, which in turn promote maternal behavior from the early postpartum to the early childhood years.

Perinatal depression and DNA methylation of oxytocin-related genes: a study of mothers and their children.

The present study investigated the association of perinatal depression (PD) with differential methylation of 3 genomic regions among mother and child dyads: exon 3 within the oxytocin receptor (OXTR) gene and 2 intergenic regions (IGR) between the oxytocin (OXT) and vasopressin (AVP) genes. Maternal PD was assessed at 5 time-points during pregnancy and postpartum. Four groups were established based on Edinburgh Postnatal Depression Scale (EPDS) cut-off scores: no PD, prenatal or postpartum depressive symptoms only and persistent PD (depressive symptoms both prenatally and postpartum). Salivary DNA was collected from mothers and children at the final time-point, 2.9years postpartum. Mothers with persistent PD had significantly higher overall OXTR methylation than the other groups and this pattern extended to 16/22 individual CpG sites. For the IGR, only the region closer to the AVP gene (AVP IGR) showed significant differential methylation, with the persistent PD group displaying the lowest levels of methylation overall, but not for individual CpG sites. These results suggest that transient episodes of depression may not be associated with OXTR hypermethylation. Validation studies need to confirm the downstream biological effects of AVP IGR hypomethylation as it relates to persistent PD. Differential methylation of the OXTR and IGR regions was not observed among children exposed to maternal PD. The consequences of OXTR hypermethylation and AVP IGR hypomethylation found in mothers with persistent PDS may not only impact the OXT system, but may also compromise maternal behavior, potentially resulting in negative outcomes for the developing child.

Birth setting, labour experience, and postpartum psychological distress.

OBJECTIVE: although psychosocial risk factors have been identified for postpartum depression (PPD) and perinatal posttraumatic stress disorder (PTSD), the role of labour- and birth-related factors remains unclear. The present investigation explored the impact of birth setting, subjective childbirth experience, and their interplay, on PPD and postpartum PTSD. METHOD: in this prospective longitudinal cohort study, three groups of women who had vaginal births at a tertiary care hospital, a birthing center, and those transferred from the birthing centre to the tertiary care hospital were compared. Participants were followed twice during pregnancy (12-14 and 32-34 weeks gestation) and twice after childbirth (1-3 and 7-9 weeks postpartum). RESULTS: symptoms of PPD and PTSD did not significantly differ between birth groups; however, measures of subjective childbirth experience and obstetric factors did. Moderation analyses indicated a significant interaction between pain and birth group, such that higher ratings of pain among women who were transferred was associated with greater symptoms of postpartum PTSD. CONCLUSION AND IMPLICATIONS FOR PRACTICE: women who are transferred appear to have a unique experience that may put them at greater risk for postpartum psychological distress. It may be beneficial for care providers to help prepare women for pain management and potential unexpected complications, particularly if it is their first childbirth.

Delusional ideation during the perinatal period in a community sample.

BACKGROUND: Despite the prevalence of mental health problems during the perinatal period, little research has examined psychotic symptoms in a community sample across pregnancy and the postpartum. Exposure to environmental risk factors, and immigration in particular, are associated with increased risk for psychotic disorders. The current investigation examined whether psychosocial risk and immigrant status would predict levels of delusional ideation across the perinatal period when controlling for depression, anxiety, and demographic factors. METHODS: A community sample of 316 pregnant women was assessed at 12-14 and 32-34weeks gestation during routine clinic visits, and at 7-9weeks postpartum during a home visit. Measures included self-report ratings of psychosocial risk (e.g., history of mental health problems or abuse, stressful life events, lack of social support), pregnancy-related anxiety, depressive symptomatology, and delusional ideation. RESULTS: There was less delusional ideation during the postpartum period than during early pregnancy. Across all time points, levels of delusional ideation were lower than in the general population. Analyses using multilevel modeling indicated significant fixed-effects for the variables time, age, partnership, being religious and prenatal anxiety, but not depressive symptomatology, on delusional ideation. Immigrant status moderated the effect of psychosocial risk such that greater psychosocial risk predicted more symptoms of delusional ideation among immigrants, but not non-immigrants. CONCLUSION: Psychosocial risk factors place immigrant women at an increased likelihood for experiencing delusional ideation during the perinatal period.

Barriers and Facilitators to the Use of Mental Health Services by Women With Elevated Symptoms of Depression and Their Partners.

This qualitative descriptive study explored the barriers and facilitators to the use of mental health services reported by women with elevated symptoms of depression in the postpartum period and their partners. Data were collected through individual semi-structured interviews of 30 heterosexual couples. Content analysis revealed five principal barriers and facilitators: (a) accessibility and proximity, (b) appropriateness and fit, (d) stigma, (e) encouraged to seek help, and (f) personal characteristics. The study highlights the importance of barriers and facilitators to be taken into consideration in order to promote the use of mental health services for women with elevated symptoms of depression in the postpartum period.

Intrapartum Synthetic Oxytocin and Its Effects on Maternal Well-Being at 2 Months Postpartum.

BACKGROUND: Synthetic oxytocin (synOT) is commonly used in labor management to induce and augment labor, and to prevent postpartum hemorrhage. However, its long-term consequences for maternal health and behavior are largely understudied. We examined the relationship between synOT and maternal oxytocin levels, breastfeeding, and maternal mental health at 2 months postpartum. METHODS: Women were recruited during pregnancy or within 48 hours of giving birth through obstetric practices and hospitals. A total of 386 women were visited in their homes at 2 months postpartum, where they completed questionnaires assessing breastfeeding, depression, anxiety, posttraumatic stress, and somatization. Oxytocin levels were obtained from blood samples and synOT dosage information was gathered from hospital charts. RESULTS: Intrapartum synOT dose was positively correlated with endogenous oxytocin levels at 2 months postpartum. Women who were exclusively breastfeeding at 2 months postpartum had received significantly less synOT compared with their nonexclusively breastfeeding counterparts. Higher synOT dose was associated with greater depressive, anxious, and somatization symptoms. SynOT dose was not associated with perinatal posttraumatic stress. CONCLUSIONS: The widespread use of synOT in managed labor warrants caution, as the influence of synOT on a new mother's well-being is evident at 2 months postpartum.

Care for Postpartum Depression: What Do Women and Their Partners Prefer?

PURPOSE: To compare the preferences of those who accept a mental health assessment and those who do not. DESIGN AND METHODS: Thirty couples participated in a qualitative study. Nineteen couples accepted a mental health assessment and 11 declined. FINDINGS: Acceptors wanted more contact with professionals. Decliners preferred support from their informal network, parental leave, and exercise. However, acceptors also cited these preferences. PRACTICE IMPLICATIONS: Nurses should tailor care to couples' preferences, helping them identify and utilize preferred resources. Mental health care might be more acceptable to decliners if provided in obstetrical care.

MATERNAL MENTAL HEALTH MODERATES THE RELATIONSHIP BETWEEN OXYTOCIN AND INTERACTIVE BEHAVIOR.

Mothers with mood or anxiety disorders exhibit less optimal interactive behavior. The neuropeptide oxytocin (OT) has been linked to more optimal interactive behaviors in mothers without mental illness, and it may play a particularly beneficial role in mothers with mood or anxiety disorders given its antidepressant and anxiolytic functions. We compared the relationship between OT and interactive behavior in mothers with and without mental health problems. Participants included 20 women diagnosed with postpartum mood or anxiety disorders (clinical sample) and 90 women with low levels of depression and anxiety during pregnancy and postpartum (community sample). At 2 months' postpartum, blood was drawn to assess maternal OT levels, and mother-infant interaction was coded for maternal sensitivity, intrusiveness, remoteness, and depressiveness. Clinical mothers exhibited less sensitive, more intrusive, and more depressive interactive behaviors than did community mothers. The groups did not differ in OT levels. Mothers with higher OT levels were less intrusive with their infants. Higher OT levels were associated with less depressive interactive behavior only in clinical mothers. OT was associated with positive interactive behaviors in both groups. In clinical mothers, the calming and soothing effects of OT may promote more relaxed, energetic, and infant-focused interactive behaviors.

Attachment security and recent stressful life events predict oxytocin levels: a pilot study of pregnant women with high levels of cumulative psychosocial adversity.

PURPOSE: Recent reports indicate that prenatal levels of the neuropeptide oxytocin (OT) are inversely related to depressive symptomatology and positively associated with more optimal interactive behaviors in mothers with high levels of cumulative psychosocial adversity (CPA). In the present pilot study, we aimed to identify factors associated with high versus low levels of OT in pregnant women with high levels of CPA. We hypothesized that insecurely attached women, and those who recently experienced stressful life events (SLE), would have lower levels of prenatal OT. METHODS: Thirty pregnant women with mood and anxiety disorders and high levels of CPA were recruited from the perinatal mental health service of a general hospital. Participants completed self-report measures of psychosocial stress and adult attachment style, and blood was then drawn to assess OT. RESULTS AND CONCLUSIONS: Lower OT levels were found among those who were insecurely attached, and among those who experienced SLE within the last year. In a multiple linear regression, both attachment security and SLE significantly contributed to a model of prenatal OT levels. These individual difference factors explained 38% of the variance in prenatal OT, which may in turn predict poorer maternal mental health and caregiving outcomes during the postpartum period.

Causes of women's postpartum depression symptoms: Men's and women's perceptions.

OBJECTIVES: To describe men's and women's perceptions of the causes of women's PPD symptoms and to explore similarities and differences between men's and women's perceptions. DESIGN: Qualitative-descriptive study involving in-depth semi-structured individual interviews and content analysis. SETTING: In-home interviews of participants recruited in two tertiary care hospitals, both in urban centres of the province of Quebec, Canada. PARTICIPANTS: Both members of 30 heterosexual couples from which women scored at least 12 on the Edinburgh Postnatal Depression Scale. FINDINGS: Participants described nine causes underlying women's depressive symptoms: societal expectations and pressure on women, physical health problems, transition to parenthood, social connectedness, personality and past psychological history, child health and temperament challenges, unmet care needs, unmet expectations for childbirth, and other life stressors. With one exception, all causes were endorsed by both men and women. Only men mentioned societal pressure on women. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Men and women mainly perceived similar causes, which could be explained by socio-cultural factors and extended paternal leaves. Understanding men's and women's perceptions could help tailoring health- care professionals' interventions to couples' needs.

The role of oxytocin in mothers' theory of mind and interactive behavior during the perinatal period.

The present longitudinal study examined the relations between plasma oxytocin, theory of mind, and maternal interactive behavior during the perinatal period. A community sample of women was assessed at 12-14 weeks gestation, 32-34 weeks gestation, and 7-9 weeks postpartum. Oxytocin during late pregnancy was significantly positively correlated with a measure of theory of mind, and predicted theory of mind ability after controlling for parity, maternal education, prenatal psychosocial risk, and general anxiety, measured during the first trimester. Theory of mind was associated with less remote and less depressive maternal interactive behavior. Oxytocin, across all time points, was not directly related to maternal interactive behavior. However, there was a significant indirect effect of oxytocin during late pregnancy on depressive maternal behavior via theory of mind ability. These preliminary findings suggest that changes in the oxytocinergic system during the perinatal period may contribute to the awareness of social cues, which in turn plays a role in maternal interactive behavior.

Psychosocial stress moderates the relationships between oxytocin, perinatal depression, and maternal behavior.

The hormone oxytocin (OT) is of particular interest in the study of childbearing women, as it has a role in the onset and course of labor and breastfeeding. Recent research has linked OT to maternal caregiving behavior towards her infant, and to postpartum depressive symptomatology. There is also evidence that psychosocial adversity affects the oxytocin system. The present study investigated the relationship of endogenous OT in women during pregnancy and at 8weeks postpartum to psychosocial stress, maternal symptoms of depression, and maternal sensitive behavior. It was hypothesized that OT would mediate the effects of maternal depressive symptoms on maternal interactive behavior. We also tested the hypothesis that psychosocial stress would moderate the relationship between OT and maternal depressive symptoms and sensitive behavior. A community sample of 287 women was assessed at 12-14weeks of gestation, 32-34weeks of gestation, and 7-9weeks postpartum. We measured plasma OT, maternal symptoms of depression and psychosocial stress. At the postpartum home visit, maternal behavior in interaction with the infant was videotaped, and then coded to assess sensitivity. In the sample as a whole, OT was not related to maternal depressive symptoms or to sensitive maternal behavior. However, among women who reported high levels of psychosocial stress, higher levels of plasma OT were associated with fewer depressive symptoms and more sensitive maternal behavior. These results suggest that endogenous OT may act as a buffer against the deleterious effects of stress, thereby protecting high risk women from developing depressive symptoms and promoting more sensitive maternal interactive behavior.

Oxytocin in pregnancy and the postpartum: relations to labor and its management.

The purpose of this study was to examine variations in endogenous oxytocin levels in pregnancy and postpartum state. We also explored the associations between delivery variables and oxytocin levels. A final sample of 272 mothers in their first trimester of pregnancy was included for the study. Blood samples were drawn during the first trimester and third trimester of pregnancy and at 8 weeks postpartum. Socio-demographic data were collected at each time point and medical files were consulted for delivery details. In most women, levels of circulating oxytocin increased from the first to third trimester of pregnancy followed by a decrease in the postpartum period. Oxytocin levels varied considerably between individuals, ranging from 50 pg/mL to over 2000 pg/mL. Parity was the main predictor of oxytocin levels in the third trimester of pregnancy and of oxytocin level changes from the first to the third trimester of pregnancy. Oxytocin levels in the third trimester of pregnancy predicted a self-reported negative labor experience and increased the chances of having an epidural. Intrapartum exogenous oxytocin was positively associated with levels of oxytocin during the postpartum period. Our exploratory results suggest that circulating oxytocin levels during the third trimester of pregnancy may predict the type of labor a woman will experience. More importantly, the quantity of intrapartum exogenous oxytocin administered during labor predicted plasma oxytocin levels 2 months postpartum, suggesting a possible long-term effect of this routine intervention, the consequences of which are largely unknown.