Anomalies in the review process and interpretation of the evidence in the NICE guideline for chronic fatigue syndrome and myalgic encephalomyelitis.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling long-term condition of unknown cause. The National Institute for Health and Care Excellence (NICE) published a guideline in 2021 that highlighted the seriousness of the condition, but also recommended that graded exercise therapy (GET) should not be used and cognitive-behavioural therapy should only be used to manage symptoms and reduce distress, not to aid recovery. This U-turn in recommendations from the previous 2007 guideline is controversial.We suggest that the controversy stems from anomalies in both processing and interpretation of the evidence by the NICE committee. The committee: (1) created a new definition of CFS/ME, which 'downgraded' the certainty of trial evidence; (2) omitted data from standard trial end points used to assess efficacy; (3) discounted trial data when assessing treatment harm in favour of lower quality surveys and qualitative studies; (4) minimised the importance of fatigue as an outcome; (5) did not use accepted practices to synthesise trial evidence adequately using GRADE (Grading of Recommendations, Assessment, Development and Evaluations trial evidence); (6) interpreted GET as mandating fixed increments of change when trials defined it as collaborative, negotiated and symptom dependent; (7) deviated from NICE recommendations of rehabilitation for related conditions, such as chronic primary pain and (8) recommended an energy management approach in the absence of supportive research evidence.We conclude that the dissonance between this and the previous guideline was the result of deviating from usual scientific standards of the NICE process. The consequences of this are that patients may be denied helpful treatments and therefore risk persistent ill health and disability.

Neuropsychiatric Symptoms After Brain Tumor Resection in Children and Adolescents: A Scoping Review.

BACKGROUND: Brain tumors are one of the most common solid tumors in pediatric populations, with their treatments having significant neuropsychiatric impact. OBJECTIVE: The objective of this study was to review the literature on neuropsychiatric sequelae after surgical resection of brain tumors in children and adolescents. METHODS: Using a scoping method, we reviewed empirical articles describing pediatric patients with brain tumors who underwent partial or total resection and examined major neuropsychiatric domains postoperatively over time. RESULTS: The initial search yielded 15,543 articles. After duplicate removal, abstract screening, and review, 44 articles were included. Cognitive deficits were the most widely studied outcomes and found to be associated with tumor location, operative variables, perioperative complications, treatment types, and psychosocial factors. Cerebellar mutism, or posterior fossa syndrome, commonly co-occurred with emotional and behavioral dysregulation after posterior fossa resections. Depression, anxiety, and somatization were frequently grouped together as "distress," with higher rates among pediatric patients with brain tumor than among healthy peers. Problematic school behaviors, antisocial, and attention-deficit traits were increased; however, several other behaviors (e.g., risky sexual behaviors, substance use) were equal or lower when compared to peers. Posttraumatic stress disorder was highly prevalent and often interfered with social functioning. Delirium, eating disorders, and longer-term outcomes received inadequate attention. CONCLUSION: Identifying risk factors of neuropsychiatric sequelae and their impact after pediatric brain tumor resection is important for prognostication and the development of tailored management strategies for these children and adolescents.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review.

BACKGROUND: Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences. OBJECTIVE: To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context. METHODS: Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes. RESULTS: We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date. CONCLUSIONS: Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context. PATIENT OR PUBLIC CONTRIBUTION: Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.

Examining the Neuropsychiatric Sequelae Postsurgical Resection of Adult Brain Tumors Through a Scoping Review.

BACKGROUND: Improving brain tumor survival rates have drawn increasing focus on neuropsychiatric and psychological outcomes. OBJECTIVE: This review characterizes the literature on neuropsychiatric sequelae after neurosurgical resection of adult brain tumors. METHODS: Using a scoping method, we reviewed articles describing patients with adult brain tumor who underwent partial or total brain resection and examined major neuropsychiatric domains after intervention. RESULTS: The initial search yielded 9903 articles. After duplicate removal, abstract screening, review, and hand searching, 81 articles were found: 63 empirical and 18 nonempirical. Most articles centered on survivorship within the first year. Cognition was most widely studied with a transient worsening during the first month and usually recovery or improvement thereafter. Depression increased in frequency during survivorship and was associated with frontotemporal location, time to survival, quality of life, cognitive and physical parameters, and functional status. Anxiety, independent of depression, related to tumor histology and grading and had a weaker association with cognition and quality of life. Obsessive-compulsive symptoms, psychosis, mania, and delirium received little attention. Most studies did not include preoperative neuropsychiatric assessment, and treatment was poorly addressed. CONCLUSION: This review highlights key gaps, including preoperative and postoperative neuropsychiatric assessment and a short follow-up. A better understanding of postresection neuropsychiatric outcomes can inform our ability to prognosticate and tailor management for patients at risk for these life-impairing conditions.

What constitutes patient-centred care for women: a theoretical rapid review.

BACKGROUND: Women experience disparities in health care delivery and outcomes. Patient-centred care for women (PCCW) is needed. This study examined how PCC has been conceptualized and operationalized in women's health research. METHODS: We conducted a theoretical rapid review of PCCW in MEDLINE, EMBASE, CINAHL and SCOPUS from 2008 to 2018 for studies involving women aged 18 years or greater with any condition, and analyzed data using an established 6-domain framework of patient-centred communication. RESULTS: We included 39 studies, which covered the following clinical areas: maternal care, cancer, diabetes, HIV, endometriosis, dementia, distal radius fracture, overactive bladder, and lupus erythematosus. The 34 (87.2%) studies that defined or described PCC varied in the PCC elements they addressed, and none addressed all 6 PCC domains. Common domains were exchanging information (25, 73.5%) and fostering the patient-clinician relationship (22, 64.7%). Fewer studies addressed making decisions (16, 47.1%), enabling patient self-management (15, 44.1%), responding to emotions (12, 35.3%), or managing uncertainty (1, 2.9%). Compared with mixed-gender studies, those comprised largely of women more frequently prioritized exchanging information above other domains. Few studies tested strategies to support PCCW or evaluated the impact of PCCW; those that did demonstrated beneficial impact on patient knowledge, satisfaction, well-being, self-care and clinical outcomes. CONCLUSIONS: Studies varied in how they conceptualized PCCW, and in many it was defined narrowly. Few studies examined how to implement or measure PCCW; thus, we lack insight on how to operationlize PCCW. Thus, further research is needed to confirm this, and whether PCCW differs across conditions, knowledge needed to inform policies, guidelines and measures aimed at improving health care and associated outcomes for women.

Healthcare providers' perspectives on the acceptability and uptake of HPV vaccines in Zimbabwe.

BACKGROUND: Human papillomavirus (HPV) vaccines are a critical strategy in the prevention of cervical cancer, especially in countries like Zimbabwe where cervical cancer screening rates are low. In Zimbabwe, cervical cancer is the leading cause of cancer-related deaths in women but the HPV vaccine is not yet widely available. This study examined healthcare providers': (1) perceptions of current hospital practices and issues in cervical cancer prevention and treatment in Zimbabwe; (2) knowledge of HPV and HPV vaccines; and (3) perspectives on introducing HPV vaccination programs in Zimbabwe, including potential facilitators and barriers to successful implementation. METHOD: In-depth semi-structured interviews were conducted at a rural hospital with 15 healthcare providers in Zimbabwe. Interviews included eight main questions and a number of additional probes that reflected the study's purpose. Data were analyzed using thematic analysis. RESULTS: Participants reported that women are not consistently being screened for cervical cancer. There were generally low levels of knowledge about HPV and HPV vaccines, but participants asked many questions indicating a desire to learn more. Although they were highly supportive of implementing HPV vaccination programs in Zimbabwe, they also identified a number of likely psychosocial, cultural, and logistical barriers to successful implementation, including cost, vaccine schedule, and hospital infrastructure. However, participants also provided a number of culturally relevant solutions, including education and community engagement. CONCLUSION: This study provides insight from healthcare providers about barriers to implementation and possible solutions that can be used by policy makers, practitioners, and other stakeholders to facilitate the successful implementation of forthcoming HPV immunization programs in Zimbabwe.

Women's Health Behaviours and Psychosocial Well-Being by Cardiac Rehabilitation Program Model: A Randomized Controlled Trial.

BACKGROUND: Cardiac rehabilitation (CR) is associated with significantly lower mortality and improved psychosocial well-being. However, women are less likely to participate than men. This trial tested whether participation in women-only CR results in better health behaviours and psychosocial outcomes than do other models. METHODS: Cardiac Rehabilitation for her Heart Event Recovery (CR4HER) was a single-blind randomized trial with 3 parallel arms. Low-risk cardiac patients were recruited from 6 sites in Ontario. Consenting participants completed surveys assessing health behaviours (physical activity, diet, medication adherence, smoking) and psychosocial well-being (social support, quality of life, depressive symptoms) and wore pedometers for 7 days. After intake assessment, eligible participants were randomized to mixed-sex, women-only, or home-based CR. Participants were mailed follow-up surveys and pedometers 6 months later. RESULTS: One hundred sixty-nine patients were randomized, and 116 (68.6%) were retained. Self-reported physical activity increased among women in mixed-sex and women-only CR groups (per protocol and as treated, P < 0.05). Diet improved among women in women-only CR groups (as treated, P < 0.05). Quality of life improved among women in mixed-sex (per protocol and as treated, P < 0.05) and women-only CR groups (per protocol, P < 0.05; as treated, P < 0.01). After testing, women in the mixed-sex CR group had higher anxiety symptoms than did those in the women-only group (per protocol, P = 0.017), and those in the mixed-sex CR group had higher depressive symptoms than did those in the women-only group (as treated, P = 0.001). Analyses adjusted for confounding variables revealed no significant differences in any outcome by model. Post hoc equivalency tests were computed on a per-protocol basis, and all outcomes were equivalent by model. CONCLUSIONS: Behavioural and psychosocial outcomes were largely equivalent regardless of model; however, women-only programs may confer an advantage for anxiety and depressive symptoms.

Depression screening and patient outcomes in pregnancy or postpartum: a systematic review.

OBJECTIVE: Clinical practice guidelines disagree on whether health care professionals should screen women for depression during pregnancy or postpartum. The objective of this systematic review was to determine whether depression screening improves depression outcomes among women during pregnancy or the postpartum period. METHODS: Searches included the CINAHL, EMBASE, ISI, MEDLINE, and PsycINFO databases through April 1, 2013; manual journal searches; reference list reviews; citation tracking of included articles; and trial registry reviews. RCTs in any language that compared depression outcomes between women during pregnancy or postpartum randomized to undergo depression screening versus women not screened were eligible. RESULTS: There were 9,242 unique titles/abstracts and 15 full-text articles reviewed. Only 1 RCT of screening postpartum was included, but none during pregnancy. The eligible postpartum study evaluated screening in mothers in Hong Kong with 2-month-old babies (N=462) and reported a standardized mean difference for symptoms of depression at 6 months postpartum of 0.34 (95% confidence interval=0.15 to 0.52, P<0.001). Standardized mean difference per 44 additional women treated in the intervention trial arm compared to the non-screening arm was approximately 1.8. Risk of bias was high, however, because the status of outcome measures was changed post-hoc and because the reported effect size per woman treated was 6-7 times the effect sizes reported in comparable depression care interventions. CONCLUSION: There is currently no evidence from any well-designed and conducted RCT that screening for depression would benefit women in pregnancy or postpartum. Existing guidelines that recommend depression screening during pregnancy or postpartum should be re-considered.

Effects of screening for psychological distress on patient outcomes in cancer: a systematic review.

OBJECTIVE: Several practice guidelines recommend routine screening for psychological distress in cancer care. The objective was to evaluate the effect of screening cancer patients for psychological distress by assessing the (1) effectiveness of interventions to reduce distress among patients identified as distressed; and (2) effects of screening for distress on distress outcomes. METHODS: CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO, and SCOPUS databases were searched through April 6, 2011 with manual searches of 45 relevant journals, reference list review, citation tracking of included articles, and trial registry reviews through June 30, 2012. Articles in any language on cancer patients were included if they (1) compared treatment for patients with psychological distress to placebo or usual care in a randomized controlled trial (RCT); or (2) assessed the effect of screening on psychological distress in a RCT. RESULTS: There were 14 eligible RCTs for treatment of distress, and 1 RCT on the effects of screening on patient distress. Pharmacological, psychotherapy and collaborative care interventions generally reduced distress with small to moderate effects. One study investigated effects of screening for distress on psychological outcomes, and it found no improvement. CONCLUSION: Treatment studies reported modest improvement in distress symptoms, but only a single eligible study was found on the effects of screening cancer patients for distress, and distress did not improve in screened patients versus those receiving usual care. Because of the lack of evidence of beneficial effects of screening cancer patients for distress, it is premature to recommend or mandate implementation of routine screening.

Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study.

BACKGROUND: Despite the evidence of benefit, cardiac rehabilitation (CR) remains highly underutilized. The present study examined the effect of two inpatient and one outpatient strategy on CR utilization: allied healthcare provider completion of referral (a policy that had been endorsed and approved by the cardiac program leadership in advance; PRE-APPROVED); CR intake appointment booked before hospital discharge (PRE-BOOKED); and early outpatient education provided at the CR program shortly after inpatient discharge (EARLY ED).In this prospective observational study, 2,635 stable cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey, and clinical data were extracted from charts. One year later, participants were a mailed survey that assessed CR use. Participating inpatient units and CR programs to which patients were referred were coded to reflect whether each of the strategies was used (yes/no). The effect of each strategy on participants' CR referral and enrollment was examined using generalized estimating equations. RESULTS: A total of 1,809 participants completed the post-test survey. Adjusted analyses revealed that the implementation of one of the inpatient strategies was significantly related to greater referral and enrollment (PRE-APPROVED: OR = 1.96, 95%CI = 1.26 to 3.05, and OR = 2.91, 95%CI = 2.20 to 3.85, respectively). EARLY ED also resulted in significantly greater enrollment (OR = 4.85, 95%CI = 2.96 to 7.95). CONCLUSIONS: These readily-implementable strategies could significantly increase access to and enrollment in CR for the cardiac population. The impact of these strategies on wait times warrants exploration.

A prospective examination of disease management program use by complex cardiac outpatients.

BACKGROUND: The use of disease management programs (DMPs) by patients with cardiovascular disease (CVD) is associated with improved outcomes. Although rates of cardiac rehabilitation (CR) use are well established, less is known about other DMPs. The objectives of this study were to describe the degree of DMP utilization by CVD outpatients, and examine factors related to use. METHODS: This study represents a secondary analysis of a larger prospective cohort study. In hospital, 2635 CVD inpatients from 11 hospitals in Ontario Canada completed a survey that assessed factors affecting DMP utilization. One year later, 1803 participants completed a mailed survey that assessed DMP utilization. RESULTS: One thousand seventy-three (59.5%) participants reported using at least 1 DMP. Overall, 951 (52.7%) reported participating in cardiac rehabilitation, and among participants with a comorbid indication, 212 (41.2%) reported attending a diabetes education centre, 28 (25.9%) attended stroke rehabilitation, 35 (12.9%) used a heart failure clinic, and 13 (11.7%) attended a smoking cessation program. A multinomial logistic regression analysis showed that compared with no DMP use, participants that attended 1 or multiple programs were younger, married, diagnosed with a myocardial infarction, less likely to have had a percutaneous coronary intervention and had higher perceptions of personal control over their heart condition. There were few differences between participants that used 1 vs multiple DMPs, however, having diabetes or comorbid stroke significantly increased the likelihood of multiple DMP use. CONCLUSIONS: Approximately 40% of CVD outpatients do not access DMPs. An integrated approach to vascular disease management appears warranted.

Listening to the heart-brain talk: persistent depressive symptoms are associated with hsCRP in apparently healthy individuals at high risk for coronary artery disease.

BACKGROUND: This study examined whether mild-to-moderate depressive symptoms are associated with increased high-sensitivity C-reactive protein (hsCRP) and interleukin 6 (IL-6) levels in apparently healthy individuals at high risk for coronary artery disease. We investigated in individuals whether: (1) current depressive symptoms were associated with increased hsCRP and IL-6 levels; (2) persistent depressive symptoms at two time points 6 months apart were associated with hsCRP and IL-6; and (3), sex-based differences in inflammation were a function of depressive symptoms. METHODS: We measured depressive symptoms (twice), hsCRP, and IL-6 (follow-up time point) in 84 apparently healthy individuals (52% women) at high cardiac risk. RESULTS: Patients with persistent depressive symptoms had higher hsCRP, compared to participants without persistent symptoms (5.55 vs. 1.70 mg/l, p < 0.05, 95% CI 0.11 to 1.09, d = 0.67). Participants with current depressive symptoms had higher hsCRP (3.99 vs. 1.70 mg/l, p = 0.059) than those without symptoms. Findings remained unchanged after controlling for covariates. Women had higher adjusted hsCRP than men (2.91 vs. 1.87 mg/l, p < 0.001). When we entered depressive symptoms, the model remained significant, with a significant interaction between sex and symptoms: women with depressive symptoms had higher hsCRP than men with depressive symptoms and than women without symptoms (6.75 vs. 1.11 mg/l). The hypothesized differences were not observed with respect to IL-6, after controlling for body mass index (95% CI-0.77 to 0.73). CONCLUSIONS: Before a first ischaemic coronary event, persistent mild-to-moderate depressive symptoms were associated with increased hsCRP. Women with depressive symptoms had higher hsCRP than men with symptoms.

Depression screening and patient outcomes in cancer: a systematic review.

BACKGROUND: Several practice guidelines recommend screening for depression in cancer care, but no systematic reviews have examined whether there is evidence that depression screening benefits cancer patients. The objective was to evaluate the potential benefits of depression screening in cancer patients by assessing the (1) accuracy of depression screening tools; (2) effectiveness of depression treatment; and (3) effect of depression screening, either alone or in the context of comprehensive depression care, on depression outcomes. METHODS: Data sources were CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases through January 24, 2011; manual journal searches; reference lists; citation tracking; trial registry reviews. Articles on cancer patients were included if they (1) compared a depression screening instrument to a valid criterion for major depressive disorder (MDD); (2) compared depression treatment with placebo or usual care in a randomized controlled trial (RCT); (3) assessed the effect of screening on depression outcomes in a RCT. RESULTS: There were 19 studies of screening accuracy, 1 MDD treatment RCT, but no RCTs that investigated effects of screening on depression outcomes. Screening accuracy studies generally had small sample sizes (median = 17 depression cases) and used exploratory methods to set sample-specific cutoff scores that varied substantially across studies. A nurse-delivered intervention for MDD reduced depressive symptoms moderately (effect size = 0.37). CONCLUSIONS: The one treatment study reviewed reported modest improvement in depressive symptoms, but no evidence was found on whether or not depression screening in cancer patients, either alone or in the context of optimal depression care, improves depression outcomes compared to usual care. Depression screening in cancer should be evaluated in a RCT in which all patients identified as depressed, either through screening or via physician recognition and referral in a control group, have access to comprehensive depression care.

Depressive symptoms as a determinant of breast and cervical cancer screening in women: a population-based study in Ontario, Canada.

The objective of this study was to investigate the relationship between depression and screening for breast and cervical cancer. The study sample included Ontario female respondents to the Canadian Community Health Survey Cycle 1.2, Mental Health and Well Being component (2002). Women with Major Depressive Disorder (MDD) were identified based on the World Mental Health Composite International Diagnostic Interview and women with clinically significant depressive symptoms were identified using the Kessler 6-item Distress Scale (K6 ≥ 8). Respondents eligible for screening (N = 4,042 for cervical cancer and N = 1,403 for breast cancer) were linked to Ontario administrative data to prospectively ascertain screening outcomes. Both women with MDD and K6 ≥ 8 were less likely to receive breast cancer screening than their non-depressed counterparts (46.1% vs. 61.5% for MDD, Χ(2) = 5.47, p = 0.02; 49.9% vs. 61.9% for K6, Χ(2) = 6.61, p = 0.01). Adjusted analyses revealed persistence of the association between K6 ≥ 8 and breast cancer screening (adjusted odds ratio (AOR) 0.63, 95% CI 0.40-0.97). Neither MDD nor K6 ≥ 8 were found to be associated with cervical cancer screening in the full sample. A sub-group analysis by age revealed that women over age 40 years with K6 ≥ 8 were less likely to receive cervical cancer screening than their non-depressed counterparts (49.9% vs. 64.5%, X(2) = 6.47, p = 0.01). This association approached statistical significance in adjusted analysis (AOR = 0.65, 95% CI 0.41-1.04). This study's findings suggest that attention to the uptake of preventive services in women with depressive symptoms is warranted.

Prenatal tobacco exposure and cortisol levels in infants of teen mothers.

AIMS: prenatal tobacco exposure (PTE) is an important public health concern for the offspring of teen mothers. We examined whether PTE is associated with baseline cortisol levels in four-month-old infants of teenage mothers. METHODS: we assessed salivary cortisol levels of 212 infants. PTE was measured by using self-reports of cigarette smoking during pregnancy. We used a propensity scores matching analysis to compare infants with PTE and those without. RESULTS: of 212 mothers, 151 smoked during pregnancy. However, there was no association between PTE and infant cortisol levels. CONCLUSIONS: we could not support a relation between PTE and cortisol levels in a sample of four-month-old infants of teenage mothers.

Post-traumatic growth among cardiac outpatients: degree comparison with other chronic illness samples and correlates.

This study evaluated the sociodemographic, clinical and behavioral correlates of post-traumatic growth (PTG) in coronary artery disease (CAD) patients, and the degree of PTG compared to other patient groups. Using a prospective design, 1497 CAD outpatients completed a survey assessing potential PTG correlates. A total of 1268 responded to a nine-month follow-up survey assessing PTG. Significant PTG correlates were being younger, non-white, having lower income, functional status, and depressive symptoms, greater social support, and positive illness perceptions. The degree of PTG was equivalent to that of cardiac patients in other countries, but was lower than that of breast cancer and multiple sclerosis patients.

Elevated brain monoamine oxidase A binding in the early postpartum period.

CONTEXT: The early postpartum period is a time of high risk for a major depressive episode (or postpartum depression), with a prevalence of 13%. During this time, there is a heightened vulnerability for low mood because postpartum blues is common. Severe postpartum blues can herald the onset of postpartum depression. The neurobiological mechanisms to explain postpartum blues and the high risk for the onset of postpartum depression in the first few weeks after delivery are unclear. Estrogen levels drop 100- to 1000-fold during the first 3 to 4 days postpartum, and changes in estrogen levels have an inverse relationship with monoamine oxidase A (MAO-A) density. However, MAO-A levels have never been measured in the early postpartum period. OBJECTIVE: To determine whether brain MAO-A binding is elevated in the early postpartum period. DESIGN: Case-control study. SETTING: Tertiary care academic psychiatric hospital in Toronto, Ontario, Canada. PARTICIPANTS: Fifteen healthy women who were 4 to 6 days postpartum and 15 healthy women who had not recently been postpartum underwent carbon 11-labeled harmine positron emission tomography scanning. All women were nonsmoking and medication free. MAIN OUTCOME MEASURE: MAO-A total distribution volume, an index of MAO-A density, was measured in prefrontal cortex, anterior cingulate cortex, anterior temporal cortex, thalamus, dorsal putamen, hippocampus, and midbrain. RESULTS: MAO-A total distribution volume was significantly elevated (mean, 43%) throughout all analyzed brain regions during the early postpartum period. CONCLUSIONS: Elevated MAO-A levels in the early postpartum period can be interpreted as a marker of a monoamine-lowering process that contributes to the mood change of postpartum blues. Rather than a purely psychosocial model, we propose a neurobiological model of estrogen decline, followed by elevated MAO-A binding, low mood, and subsequently a period of high risk for major depressive episodes. Our model has important implications for preventing postpartum depression and for developing therapeutic strategies that target or compensate for elevated MAO-A levels during postpartum blues.