Mental Health and Placenta Accreta Spectrum.

Nearly half of women describe childbirth as traumatic in some way, making them more vulnerable to perinatal psychiatric illness. Patients with high risk pregnancies, such as abnormal placentation, are even more susceptible to childbirth related mental health sequelae. There are no formal recommendations for mental health intervention in women with placenta accreta spectrum (PAS). In many institutions, the Edinburgh Postpartum Depression Scale is used to assess for depressive and anxiety symptoms during pregnancy and postpartum. Women with PAS should be screened at time of diagnosis, monthly until delivery, and at multiple time points through the first year postpartum. It is also recommended to screen women for PTSD prior to and after delivery. Interventions shown helpful in the PAS population include establishing a multidisciplinary team, patient access to a support person or care coordinator, development of a postpartum care team and plan, and extending mental health follow up through the first year postpartum. Women with PAS are at increased risk for negative mental health outcomes. To support the mental health of women with PAS and their families, we recommend a multi-disciplinary treatment team, screening for mental health sequelae early and often, referring women with positive screens to mental health professionals, involving the partner/family in care, and considering referral to a PAS support group for peer support.

Outcomes of Implementing Routine Screening and Referrals for Perinatal Mood Disorders in an Integrated Multi-site Pediatric and Obstetric Setting.

PURPOSE: We report on a successful quality improvement project designed to increase access to perinatal mental health services through universal screening for postpartum depression (PPD) and facilitating referrals for evaluation and treatment, at a multi-site, integrated system of pediatric and obstetric practices in Houston, Texas. DESCRIPTION: Obstetric practices administered screenings twice during pregnancy and at 6 weeks postpartum. Pediatric practices screened women at the 2 week and 2, 4, and 6-month well-baby visit. Women with a score of 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) or women that reported thoughts of self-harm were offered a referral to a mental health provider. Data on screening and referrals were collected from the electronic medical record. RESULTS: A total of 102,906 screens for PPD were completed between May 2014 and July 2018. Of those, 6487 (6.3%) screened positive. The total number of women referred to treatment were 3893 (3.8%). Of referred women 2172 (55.8%) completed an appointment with a mental health provider within 60 days of referral. Rates of completed appointments varied by the level of integration of the mental health provider and referring physician: women referred by pediatrics in a Level 1 coordinated system completed 20.0% of referrals; obstetrics Level 4 co-located system, 76.6%; and obstetrics Level 5 integrated model, 82.7%. CONCLUSION: This project demonstrated that with planning, systems review and trained staff, PPD screening can be integrated into obstetric and pediatric practices and high screening and referral rates can be achieved.

Perceived worsening of obsessive-compulsive disorder symptoms after childbirth in women and men: An understudied phenomenon.

The aim of this study was to examine worsening of OCD symptoms after childbirth in individuals seeking assessment or treatment of OCD. The postpartum period may make parents biologically and psychologically vulnerable to OCD symptoms. Participants included 222 parents with OCD who completed surveys through a self-help website. Most women and almost half of men with self-reported OCD reported an increase in OCD symptoms following childbirth. Retrospective report of perceived worsening of OCD symptoms after childbirth was associated with more aggressive obsessions for both men and women, in comparison to individuals whose OCD symptoms did not worsen around childbirth. Women whose OCD symptoms worsened after childbirth reported more impairment in social functioning than individuals whose symptoms did not worsen. These results highlight the need to develop a better understanding of aggressive obsessions in parents, and improve education about prevalence, content, assessment, and intervention for aggression-focused intrusive thoughts.

Longer wait time after identification of peripartum depression symptoms is associated with increased symptom burden at psychiatric assessment.

Untreated peripartum depression (PD) affects one in seven women and is associated with negative maternal outcomes. This retrospective observational study used health record data from an integrated health system in Texas to assess the extent to which time to access reproductive psychiatry influences the mental health of peripartum women. Women with at least one screening for depression symptoms conducted in obstetric or pediatric settings between May 2014 and October 2019 and subsequently seen by the reproductive psychiatry clinic (n=490) were included. Descriptive and inferential statistics were used to assess timing and factors related to psychiatry follow-up. Findings from this study demonstrated that the average time between a positive screen and a psychiatry assessment was 5 weeks. At psychiatry referral appointments, 85% of women continued to screen positive for PD symptoms. Depression symptom scores at the psychiatry appointment were significantly higher than scores precipitating the referral (p = 0.002). Wait time between initial positive screen and referral appointment was positively correlated with clinically meaningful increases in depression symptom scores (p < 0.001). Each week spent waiting for an appointment produced a 13% increase in odds of clinically meaningful worsening of PD scores and 9% increase in odds of developing new self-harm ideation. Given the findings that a longer period between primary care referral and subspecialty appointment has a negative impact on the mental health of women, this study supports the need for earlier psychiatric assessment to minimize decompensation. Expansion of reproductive psychiatry services are needed to support peripartum women and improve maternal outcomes.

A double-blind, placebo-controlled study of the omega-3 fatty acid docosahexaenoic acid in the treatment of major depression.

OBJECTIVE: This study was an evaluation of the omega-3 fatty acid docosahexaenoic acid (DHA) for the treatment of major depression. METHOD: Thirty-six depressed patients were randomly assigned to receive DHA, 2 g/day, or placebo for 6 weeks. Response was defined a priori as a > or =50% reduction in the score on the Montgomery-Asberg Depression Rating Scale. Thirty-five participants were evaluable; 18 received DHA, and 17 received placebo. RESULTS: Response rates were 27.8% in the DHA group and 23.5% in the placebo group. The difference in response rates between groups did not reach statistical significance. CONCLUSIONS: This trial failed to show a significant effect of DHA monotherapy in subjects with major depression.

Breast and colorectal cancer screening among low-income women with psychiatric disorders.

This study investigated breast and colorectal cancer screening among 196 low-income women being treated for psychiatric illnesses. Main outcome measures included breast self-examination (BSE), clinical breast examination (CBE), mammography, digital rectal examination (DRE), and fecal occult blood test (FOBT). Results indicated that 49% and 66% of women 40 years of age or older had obtained mammograms and CBEs, respectively, in the preceding year. Forty-four per cent of women 20 years of age or older reported monthly BSE. Forty-six per cent and 35% of women 50 years of age or older reported having digital rectal exams (DRE) or fecal occult blood tests (FOBT), respectively, in the preceding year. Multivariate analyses showed that physician recommendation of screening was the strongest predictor of having obtained a mammogram, CBE, DRE or FOBT in the preceding year. Physician recommendation and self-confidence in performing BSE were the strongest predictors of monthly BSE. These results highlight the importance of physician recommendation of adherence to screening guidelines for breast and colorectal cancer. Because psychiatrists frequently treat psychiatric patients on a regular basis, they are in a unique position to encourage cancer screening and to monitor compliance with their recommendations.

Omega-3 fatty acids for the prevention of postpartum depression: negative data from a preliminary, open-label pilot study.

Based on the putative relationship between depleted omega-3 fatty acids and postpartum depression, we initiated an open-label pilot study of omega-3 fatty acid supplementation with the aim of preventing postpartum depression. Euthymic pregnant females with a past history of depression in the postpartum period were started on 2960 mg of fish oil (1.4:1 eicosapentaenoic acid:docosahexaenoic acid) per day between the 34th to 36th week of pregnancy and assessed through 12 weeks postpartum. Four of seven participants had a depressive episode during the study period. No participants withdrew from the study due to adverse events. This preliminary, small, open-label pilot study failed to show promising results for the use of omega-3 fatty acid monotherapy beginning at 34 to 36 weeks gestation for the prevention of postpartum depression in patients with a prior postpartum depression history. Controlled studies are lacking.