Interactions of perinatal depression versus anxiety and infants' early temperament trajectories.

This study examines the interplay between maternal depression/anxiety and infant temperament's developmental trajectory in 1687 Swedish-speaking mother-infant dyads from Uppsala County (2009-2019), Sweden. The sample includes a high proportion of university-educated individuals and a low share of foreign-born participants. Maternal depressive and anxiety symptoms were assessed using the Edinburgh Postnatal Depression Scale during gestational weeks 17 and 32 and postpartum at week 6. Multinomial regression explored associations between maternal variables and infant temperament trajectories at 6 weeks, 12 months, and 18 months. Prenatal anxiety is associated with the high-rising infant difficult temperament trajectory, while prenatal depression/anhedonia is associated with the stable-medium trajectory, attenuated postpartum. Associations between infant temperament and maternal mood depended on timing (pre/postpartum) and symptom type (depression/anhedonia vs. anxiety).

The microbiota-gut-brain axis and perceived stress in the perinatal period.

Perinatal perceived stress can contribute to worse health outcomes for the parent-child dyad. Given the emerging relationship between the microbiota-gut-brain axis and stress, this study sought to elucidate connections between bowel symptoms and the gut microbiome in relation to perceived stress at three time points in the perinatal period: two during pregnancy and one postpartum. Ninety-five pregnant individuals participated in a prospective cohort study from April 2017 to November 2019. Researchers assessed Perceived Stress Scale-10 (PSS); bowel symptoms (according to the IBS Questionnaire); psychiatrist assessment of new onset or exacerbated depression and anxiety; and fecal samples analyzed for alpha diversity (measures of gut microbiome diversity utilizing Shannon, Observed OTUs, and Faith's PD) at each timepoint. Covariates included weeks of gestation and weeks postpartum. PSS scores were divided into "Perceived Self-Efficacy" and "Perceived Helplessness." Increased gut microbial diversity was associated with decreased bowel symptoms, decreased overall perceived stress, increased ability to cope with adversity, and decreased distress in the postpartum period. This study found a significant association between a less diverse microbial community, lower self-efficacy early in pregnancy, and greater bowel symptoms and perceived helplessness later in the perinatal period, relationships that may ultimately point to novel diagnostic methods and interventions for perceived stress based on the microbiota-gut-brain axis.

A Qualitative Study of Religion and Spirituality in a Perinatal Psychiatry Inpatient Unit in the Southeast USA.

Religion and spirituality are important aspects of culture that can interact with mental health. They can also be central components of women's experiences during pregnancy and the postpartum period. This study aims to explore the role of religion and spirituality among women experiencing severe psychopathology during the perinatal period using qualitative interviews of women hospitalized during pregnancy or postpartum on an inpatient unit in the Southeast USA. The average age of participants was 34.2 and all identified as white, aside from one who identified as other. Though religious affiliation was varied, most participants were Christian. Each patient interviewed had a diagnosis of depressive disorder, among other comorbid diagnoses. Three main themes emerged in the subsequent analyses (1) spirituality providing a sense of healing and connectedness above and beyond religion, (2) patients seeking support from religious leaders, and (3) patients experiencing familial pressure to enact religion in a certain way, especially as it relates to child rearing. Clinical implications for each of the themes are explored.

The Crisis of Perinatal Mental Health in the Age of Covid-19.

In the US, the COVID-19 pandemic adds a new source of stress for women in the perinatal period, a time when stress and anxiety are already heightened. The closures of physical mental health care spaces and lack of support could have devastating impacts on the health of postpartum women and their newborns. Yet, the pandemic creates an opportunity to innovate in the ways mental health care is delivered to pregnant and postpartum women. With the expanded capacity for video and telephone visits, researchers should continue to explore solutions for providing support networks to this vulnerable population.

Toward a framework for best practices and research guidelines for perinatal depression research.

This review article highlights the current state of perinatal depression (PND) research including established standards of care and innovative research in progress. PND can have a significant adverse impact on mother, child, and family; however, to date, wide-scale identification, prevention, and treatment have been limited. PND is heterogenous in presentation with likely multifactorial etiologies for each woman. Challenges in PND research are discussed including a need for universal tools, standardized measures, benchmarks, and best practices. Current examples are reviewed that highlight approaches to novel treatment paradigms and interventions. This includes reviewing epidemiologic studies in PND research, examining the biological underpinnings of PND, and discussing examples from this field and other fields currently developing translational research that spans from bench to bedside. Current and future challenges and opportunities in developing best practices for the treatment of PND are outlined. We also discuss the use of the NIMH Research Domain Criteria approach for PND research and provide recommendations for future directions in PND research collaboration. In conclusion, greater precision in perinatal psychiatry can be possible in the future with the development of guidelines and best practices that build on current work and apply innovative and collaborative approaches of scientists, providers, patients, community members, and government officials.

Can social support during pregnancy affect maternal DNA methylation? Findings from a cohort of African-Americans.

BACKGROUND: While stress and the absence of social support during pregnancy have been linked to poor health outcomes, the underlying biological mechanisms are unclear. METHODS: We examined whether adverse experiences during pregnancy alter DNA methylation (DNAm) in maternal epigenomes. Analyses included 250 African-American mothers from the Boston Birth Cohort. Genome-wide DNAm profiling was performed in maternal blood collected after delivery, using the Infinium HumanMethylation450 Beadchip. Linear regression models, with adjustment of pertinent covariates, were applied. RESULTS: While self-reported maternal psychosocial lifetime stress and stress during pregnancy was not associated with DNAm alterations, we found that absence of support from the baby's father was significantly associated with maternal DNAm changes in TOR3A, IQCB1, C7orf36, and MYH7B and that lack of support from family and friends was associated with maternal DNA hypermethylation on multiple genes, including PRDM16 and BANKL. CONCLUSIONS: This study provides intriguing results suggesting biological embedding of social support during pregnancy on maternal DNAm, warranting additional investigation, and replication.

The Relationship Between Perinatal Mental Health and Stress: a Review of the Microbiome.

PURPOSE OF REVIEW: Our current understanding of the underlying mechanisms and etiologies of perinatal mood and anxiety disorders (PMADs) is not clearly identified. The relationship of stress-induced adaptations (i.e., the hypothalamic-pituitary-adrenal (HPA) axis, the autonomic nervous system (ANS), the immune system) and the microbiota are potential contributors to psychopathology exhibited in women during pregnancy and postpartum and should be investigated. RECENT FINDINGS: The stress response activates the HPA axis and dysregulates the ANS, leading to the inhibition of the parasympathetic system. Sustained high levels of cortisol, reduced heart variability, and modulated immune responses increase the vulnerability to PMAD. Bidirectional communication between the nervous system and the microbiota is an important factor to alter host homeostasis and development of PMAD. Future research in the relationship between the psychoneuroimmune system, the gut microbiota, and PMAD has the potential to be integrated in clinical practice to improve screening, diagnosis, and treatment.

Anxiety and physical health problems increase the odds of women having more severe symptoms of depression.

Severely depressed women incur substantial disability and suicide risk, necessitating an understanding of factors that may contribute to severe depression. The purpose of this research was to determine the degree to which age, physical morbidity, anxiety, and hormonal status predict the likelihood of severe depression among women with mood disorders (n = 298). Data arose from a standardized battery of measures in a multi-center clinical registry of patients with mood disorders. The women were being treated at 17 participating sites of the National Network of Depression Centers. Results of logistic regression analyses indicate that a woman's level of anxiety was the strongest predictor of her likelihood of having severe depression (Exp(B) = 1.33, p = .000), including thoughts of death or suicide. The number of physical health problems that a woman reported was also a significant predictor (Exp(B) = 1.09, p = .04). Neither age nor hormonal status was significant in the final model, although a trend was observed for women with surgically induced menopause to have more severe depression. Findings support the need to work closely with medical practitioners to address physical health problems as part of the treatment plan for depression and to give comorbid anxiety and depression equal priority in symptom management.

Treatment of severe perinatal mood disorders on a specialized perinatal psychiatry inpatient unit.

Perinatal patients with bipolar and psychotic mood disorder exacerbations are challenging to treat and often receive suboptimal care. We sought to examine the treatment patterns and outcomes on one of the only US-based Perinatal Psychiatry Inpatient Units (PPIU). Perinatal patients admitted to the PPIU completed self-report measures at admission and before discharge. Retrospective chart reviews extracted history, diagnoses (current and past), and medication treatment. Patients who had discharge diagnoses of bipolar disorder, major depression with psychotic features, or postpartum psychosis were included. Forty-seven met the diagnostic inclusion criteria. Over an average length of stay (ALOS) of 9.96 days, there was significant improvement in depressive and anxiety symptoms and daily functioning (Work and Social Adjustment Scale). Psychiatric comorbidity was common. Polypharmacy was utilized in 87 %. The most common medications prescribed at discharge were antipsychotics, alone or in combination with mood stabilizers or antidepressants. ECT was performed in 10 % of cases. The complexity of patients with severe mood disorders or psychosis admitted to the PPIU supports individualized treatment plans that address both primary diagnosis and psychiatric comorbidities. Our results provide important information that can be disseminated to others to improve clinical outcomes for severe perinatal mood disorders.

The Maternal Microbiome as a Map to Understanding the Impact of Prenatal Stress on Offspring Psychiatric Health.

Stress and psychiatric disorders have been independently associated with disruption of the maternal and offspring microbiome and with increased risk of the offspring developing psychiatric disorders, both in clinical studies and in preclinical studies. However, the role of the microbiome in mediating the effect of prenatal stress on offspring behavior is unclear. While preclinical studies have identified several key mechanisms, clinical studies focusing on mechanisms are limited. In this review, we discuss 3 specific mechanisms by which the microbiome could mediate the effects of prenatal stress: 1) altered production of short-chain fatty acids; 2) disruptions in TH17 (T helper 17) cell differentiation, leading to maternal and fetal immune activation; and 3) perturbation of intestinal and microbial tryptophan metabolism and serotonergic signaling. Finally, we review the existing clinical literature focusing on these mechanisms and highlight the need for additional mechanistic clinical research to better understand the role of the microbiome in the context of prenatal stress.

Heart rate variability in late pregnancy: exploration of distinctive patterns in relation to maternal mental health.

Exploration of photoplethysmography (PPG), a technique that can be translated to the clinic, has the potential to assess the autonomic nervous system (ANS) through heart rate variable (HRV) in pregnant individuals. This novel study explores the complexity of mental health of individuals in a clinical sample responding to a task in late pregnancy; finding those with several types of past or current anxiety disorders, greater trait anxiety, or greater exposure to childhood traumatic events had significantly different HRV findings from the others in the cohort. Lower high frequency (HF), a measure of parasympathetic activity, was found for women who met the criteria for the history of obsessive-compulsive disorder (OCD) (p = 0.004) compared with women who did not meet the criteria for OCD, and for women exposed to greater than five childhood traumatic events (p = 0.006) compared with those exposed to four or less childhood traumatic events. Conversely higher low frequency (LF), a measure thought to be impacted by sympathetic system effects, and the LF/HF ratio was found for those meeting criteria for a panic disorder (p = 0.006), meeting criteria for social phobia (p = 0.002), had elevated trait anxiety (p = 0.006), or exposure to greater than five childhood traumatic events (p = 0.004). This study indicates further research is needed to understand the role of PPG and in assessing ANS functioning in late pregnancy. Study of the impact of lower parasympathetic functioning and higher sympathetic functioning separately and in conjunction at baseline and in relation to tasks during late pregnancy has the potential to identify individuals that require more support and direct intervention.

Infant gut microbiome composition is associated with non-social fear behavior in a pilot study.

Experimental manipulation of gut microbes in animal models alters fear behavior and relevant neurocircuitry. In humans, the first year of life is a key period for brain development, the emergence of fearfulness, and the establishment of the gut microbiome. Variation in the infant gut microbiome has previously been linked to cognitive development, but its relationship with fear behavior and neurocircuitry is unknown. In this pilot study of 34 infants, we find that 1-year gut microbiome composition (Weighted Unifrac; lower abundance of Bacteroides, increased abundance of Veillonella, Dialister, and Clostridiales) is significantly associated with increased fear behavior during a non-social fear paradigm. Infants with increased richness and reduced evenness of the 1-month microbiome also display increased non-social fear. This study indicates associations of the human infant gut microbiome with fear behavior and possible relationships with fear-related brain structures on the basis of a small cohort. As such, it represents an important step in understanding the role of the gut microbiome in the development of human fear behaviors, but requires further validation with a larger number of participants.

Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review.

Both acute and chronic stress can cause allostatic overload, or long-term imbalance in mediators of homeostasis, that results in disruptions in the maternal-placental-fetal endocrine and immune system responses. During pregnancy, disruptions in homeostasis may increase the likelihood of preterm birth and preeclampsia. Expectant mothers traditionally have high rates of anxiety and depressive disorders, and many are susceptible to a variety of stressors during pregnancy. These common life stressors include financial concerns and relationship challenges and may be exacerbated by the biological, social, and psychological changes occurring during pregnancy. In addition, external stressors such as major weather events (eg, hurricanes, tornados, floods) and other global phenomena (eg, the coronavirus disease 2019 pandemic) may contribute to stress during pregnancy. This review investigates recent literature published about the use of nonpharmacologic modalities for stress relief in pregnancy and examines the interplay between psychiatric diagnoses and stressors, with the purpose of evaluating the feasibility of implementing nonpharmacologic interventions as sole therapies or in conjunction with psychotherapy or psychiatric medication therapy. Further, the effectiveness of each nonpharmacologic therapy in reducing symptoms of maternal stress is reviewed. Mindfulness meditation and biofeedback have shown effectiveness in improving one's mental health, such as depressive symptoms and anxiety. Exercise, including yoga, may improve both depressive symptoms and birth outcomes. Expressive writing has successfully been applied postpartum and in response to pregnancy challenges. Although some of these nonpharmacologic interventions can be convenient and low cost, there is a trend toward inconsistent implementation of these modalities. Future investigations should focus on methods to increase ease of uptake, ensure each option is available at home, and provide a standardized way to evaluate whether combinations of different interventions may provide added benefit.

Improving Mental Health for the Mother-Infant Dyad by Nutrition and the Maternal Gut Microbiome.

Perinatal mood and anxiety disorders (PMAD) have significant negative impacts on mother and child, yet treatments are limited. Adequate nutrition during the perinatal period is essential to maternal and infant health, including maternal mental health and the child's neurologic and neuropsychiatric development. Nutrition holds promise to improve prevention and treatment of PMAD. The ability to manipulate the gut microbiota composition and structure through host nutrition and to harness the gut microbes for improved individualized nutrition may be an important new direction for prevention and treatment of PMAD, thus improving the mental health of mother and child.

Pharmacologic Treatment of Perinatal Depression.

This review provides information about medications used to treat perinatal depression, including guidance around when to use certain medications and when to consult a mental health provider. For each group of medications, including selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, mirtazapine, bupropion, lithium, atypical antipsychotics, and lamotrigine, the risks and benefits of treatment during pregnancy and lactation are reviewed, and unique qualities of each medication. A treatment algorithm is included and a description of the Food and Drug Administration's approach to providing information about medications. The article also discusses hormone therapies and future directions for new pharmacologic treatments.

Emerging literature in the Microbiota-Brain Axis and Perinatal Mood and Anxiety Disorders.

Perinatal Mood and Anxiety Disorders (PMAD) are common and can cause significant morbidity and mortality for mother and child. A healthy perinatal period requires significant adaptations; however, systems can become imbalanced resulting in depressive and anxiety symptoms. The interface between the microbiome, the immune system, and the stress system may be a model for understanding mechanisms underlying PMAD. Emerging literature from general populations regarding immune, hormone, and HPA axis changes in relation to the microbiome combined with literature on immune, gonadotropin, and stress systems in the perinatal period provides a background. We systematically investigated literature in the developing field of the microbiome in relation to PMAD. Our inclusion criteria were 1) reporting measure of maternal mood, stress, or anxious or depressed behavior; 2) in the perinatal period, defined as pregnancy through one year postpartum; and 3) reporting measure of maternal microbiome including manipulations of the microbiome through prebiotics, probiotics, or interventions with microbial byproducts. The review identified research studying associations between stress and maternal microbiome; dietary impacts on microbial composition, mood, and stress; and the relationship between the microbiome and the immune system through immunoregulatory mechanisms. Important themes identified include: the importance of studying the maternal microbiome and measures of stress, anxiety, and depression and that multi-hit models will be needed as research strives to determine the effects of multiple mechanisms working in concert.

Maternal Experiences in a Parenting Group Delivered in an Urban General Pediatric Clinic.

Untreated perinatal mood and anxiety disorders can result in impaired maternal-infant interactions. Pediatricians have a unique opportunity to identify and support mothers with mood and anxiety disorders. A parenting intervention, Circle of Security, was delivered in a pediatric clinic targeting women with mood and anxiety disorders. A qualitative assessment of the program's acceptability, participant engagement, and general experiences was conducted. Data collection included medical record abstraction, semistructured psychiatric diagnostic interviews, and semistructured questionnaires. Findings indicate Circle of Security is a feasible and practical approach to providing parenting support to women of young children with mood and anxiety disorders in the pediatric medical home. Additional larger studies will be helpful in tracking outcomes of participating women and infants and in further aiding pediatricians in teaching about attachment and emotions, empowering mothers to talk about their struggles, and ensuring support for mothers in reflecting on their emotions and experiences that affect parenting.

Integrating Maternal Mental Health Care in the Pediatric Medical Home: Treatment Engagement and Child Outcomes.

Maternal depression is associated with an array of poor child health outcomes, and low-income women face many barriers to accessing treatment. In this pilot study, we assessed treatment engagement in a maternal mental health clinic staffed by a case manager and psychiatrist in an urban pediatric practice. We also examined factors associated with engagement as well as child health outcomes and health care use. Nearly half of the women enrolled attended at least 4 sessions with a psychiatrist in 6 months. Text messaging with the case manager was associated with a greater compliance with psychiatrist sessions. Comparing index children with their siblings prior to enrollment, a higher percentage had immunizations up to date at 1 year of age (82% vs 43%, P = .01), and well-child visit compliance trended toward significance (65% vs 35%, P = .06). The pediatric setting holds promise as an innovative venue to deliver maternal mental health care.

Four cases of takotsubo cardiomyopathy linked with exacerbations of psychiatric illness.

Objective. Takotsubo cardiomyopathy is a rare cardiac syndrome most often occurring in post-menopausal women after an acute episode of severe emotional or physical stress. Prior literature suggests a higher prevalence of anxiety and depression among patients with Takotsubo cardiomyopathy. We observed four cases of Takotsubo cardiomyopathy at one tertiary care center preceded by and concurrent with exacerbations of psychiatric illness rather than after acute episodes of stress. We examined each to further understand Takotsubo cardiomyopathy's pathogenesis and relationship to psychiatric illness.Methods. We retrospectively reviewed four consecutive cases of Takotsubo cardiomyopathy at one tertiary center from August 2009 to October 2009. The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision criteria were used to diagnose psychiatric illness. Each patient was diagnosed with Takotsubo cardiomyopathy via cardiac catheterization.Results. Each woman (age range 53-67 years) was previously diagnosed with psychiatric illness. Psychiatric illnesses were as follows: Alzheimer's dementia with psychotic features, adjustment disorder, major depressive disorder, and bipolar affective disorder type 1. All four cases demonstrated exacerbations of their psychiatric illness just prior to and concurrent with their diagnosis of Takotsubo cardiomyopathy. They showed improved left ventricular ejection fraction within 1 to 3 weeks after diagnosis with supportive care.Conclusions. Differing from the traditional cases of Takotsubo cardiomyopathy, which follow acute events of stress, our four cases indicate exacerbations of underlying psychiatric illness can lead to Takotsubo cardiomyopathy. In addition to anxiety and depression, psychosis and mania may predispose an individual to Takotsubo cardiomyopathy. We suggest that cardiologists and psychiatrists be aware of this association and screen patients. We suggest further studies that may help better understand the connection between the heart and mind.