Dysphoric milk ejection reflex - call for future trials.

Dysphoric milk ejection reflex is a condition that causes an abrupt emotional downturn during the initial moments of milk ejection in a breastfeeding mother. Depression, anxiety, hopelessness, anger, irritability, homesickness, and stomach hollowness are all possible symptoms. The exact cause of D-MER remains unknown. However, it is proposed that it is caused by an alteration in oxytocin signaling response where secretion of oxytocin upregulates the stress response instead of its downregulation. Activation of the defensive response of the mother by oxytocin during breastfeeding, disruption in dopamine levels, and activation of vasopressin-regulated pathways are other probable causes. Due to a lack of awareness, this phenomenon is easily misdiagnosed as postpartum depression and aversion by many healthcare professionals. Its prevalence in various populations of the world remains unknown due to the lack of research studies conducted in these populations. While no medically approved therapeutic strategy is available, supportive techniques such as maintaining a healthy diet, mental distraction, relaxation methods, and increasing skin-to-skin contact can help alleviate dysphoria during breastfeeding. However, due to a lack of D-MER research, specific challenges exist regarding early withdrawal from breastfeeding and women's help-seeking attitude toward perinatal mental health.

Perinatal depression: Heterogeneity of disease and in animal models.

Perinatal depression (PND) can have either an antepartum or postpartum onset. Although the greatest risk factor for PND is previous depression history,de novoPND occurs with the majority of cases occurring in the postpartum. Timing of depression can impact etiology, prognosis, and response to treatment. Thus, it is crucial to study the impact of the heterogeneity of PND for better health outcomes. In this review, we outline the differences between antepartum and postpartum depression onset of PND. We discuss maternal physiological changes that differ between pregnancy and postpartum and how these may differentially impact depression susceptibility. We highlight changes in the maternal steroid and peptide hormone levels, immune signalling, serotonergic tone, metabolic factors, brain morphology, and the gut microbiome. Finally, we argue that studying the heterogeneity of PND in clinical and preclinical models can lead to improved knowledge of disease etiopathology and treatment outcomes.

Adaptations in reward-related behaviors and mesolimbic dopamine function during motherhood and the postpartum period.

Initiation and maintenance of maternal behavior is driven by a complex interaction between the physiology of parturition and offspring stimulation, causing functional changes in maternal brain and behavior. Maternal behaviors are among the most robust and rewarding motivated behaviors. Mesolimbic dopamine (DA) system alterations during pregnancy and the postpartum enable enhanced reward-related responses to offspring stimuli. Here, we review behavioral evidence demonstrating postpartum rodents exhibit a bias towards pups and pup-related stimuli in reward-related tasks. Next, we provide an overview of normative adaptations in the mesolimbic DA system induced by parturition and the postpartum, which likely mediate shifts in offspring valence. We also discuss a causal link between dopaminergic dysfunction and disrupted maternal behaviors, which are recapitulated in postpartum depression (PPD) and relevant rodent models. In sum, mesolimbic DA system activation drives infant-seeking behavior and strengthens the mother-infant bond, potentially representing a therapeutic target for reward-related deficits in PPD.

The peripartum human brain: Current understanding and future perspectives.

The peripartum period offers a unique opportunity to improve our understanding of how dramatic fluctuations in endogenous ovarian hormones affect the human brain and behavior. This notwithstanding, peripartum depression remains an underdiagnosed and undertreated disorder. Here, we review recent neuroimaging findings with respect to the neuroplastic changes in the maternal brain during pregnancy and the postpartum period. We seek to provide an overview of multimodal neuroimaging designs of current peripartum depression models of hormone withdrawal, changes in monoaminergic signaling, and maladaptive neuroplasticity, which likely lead to the development of a condition that puts the lives of mother and infant at risk. We discuss the need to effectively integrate the available information on psychosocial and neurobiological risk factors contributing to individual vulnerability. Finally, we propose a systematic approach to neuroimaging the peripartum brain that acknowledges important co-morbidities and variation in disease onset.

Pregnancy, postpartum and parity: Resilience and vulnerability in brain health and disease.

Risk and resilience in brain health and disease can be influenced by a variety of factors. While there is a growing appreciation to consider sex as one of these factors, far less attention has been paid to sex-specific variables that may differentially impact females such as pregnancy and reproductive history. In this review, we focus on nervous system disorders which show a female bias and for which there is data from basic research and clinical studies pointing to modification in disease risk and progression during pregnancy, postpartum and/or as a result of parity: multiple sclerosis (MS), depression, stroke, and Alzheimer's disease (AD). In doing so, we join others (Shors, 2016; Galea et al., 2018a) in aiming to illustrate the importance of looking beyond sex in neuroscience research.

Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics.

Postpartum depression (PPD) is common, disabling, and treatable. The strongest risk factor is a history of mood or anxiety disorder, especially having active symptoms during pregnancy. As PPD is one of the most common complications of childbirth, it is vital to identify best treatments for optimal maternal, infant, and family outcomes. New understanding of PPD pathophysiology and emerging therapeutics offer the potential for new ways to add to current medications, somatic treatments, and evidence-based psychotherapy. The benefits and potential harms of treatment, including during breastfeeding, are presented.

Lived experiences of Ugandan women who had recovered from a clinical diagnosis of postpartum depression: a phenomenological study.

BACKGROUND: Postpartum depression affects a significant proportion of women of childbearing age. The birth of a newborn baby is normally considered a joyful event, inhibiting mothers from expressing their depressive feelings. If the condition is not well understood and managed, mothers with postpartum depression are likely to experience suicidal ideation or even commit suicide. This study explored lived experiences of women who had recovered from a clinical diagnosis of postpartum depression in southwestern Uganda. METHODS: This phenomenological study adopted the explorative approach through in-depth interviews as guided by the biopsychosocial model of depression. It was conducted in Mbarara Regional Referral Hospital, Bwizibwera Health Centre IV and Kinoni Health Centre IV located in Mbarara and Rwampara districts, southwestern Uganda. Data were collected from 30 postpartum mothers who were purposively selected, between 9th December 2019 and 25th September 2020. We analyzed this work using thematic data analysis and this was steered by the Colaizzi's six-step phenomenological approach of inquiry. RESULTS: The findings were summarized into five major themes: 1) somatic experiences including insomnia and headache, breast pain, poor breast milk production, weight loss and lack of energy; 2) difficulties in home and family life including overwhelming domestic chores, lack of social support from other family members, fighting at home and financial constraints due to COVID-19 pandemic; 3) negative emotions including anger, self-blame, despondency and feelings of loneliness and regrets of conceiving or marriage; 4) feelings of suicide, homicide and self-harm including suicidal ideation and attempt, homicidal ideations and attempt and feelings of self-harm and 5) coping with postpartum depression including spirituality, termination of or attempt to leave their marital relationships, acceptance, counselling and seeking medical treatment, perseverance. CONCLUSION AND RECOMMENDATIONS: Suicidal and homicidal thoughts are important parts of the postpartum depression experience, and these may put the lives of the mothers, their spouses and their babies at a great risk. Poor relationship quality, intimate partner violence and lack of financial resources contribute significantly to the negative emotional experiences of mothers with PPD.

Inflammation and kynurenine pathway dysregulation in post-partum women with severe and suicidal depression.

Depression during pregnancy and the post-partum is common, with severe cases resulting in suicidal behavior. Despite the urgent and unmet medical need, the biological underpinnings of peri-partum depression remain unclear. It has been suggested that it is triggered by dynamic changes of the immune system during pregnancy and at delivery. Therefore, we investigated whether a pro-inflammatory status in plasma, together with changes in the kynurenine pathway activity, is associated with the development of severe depression and suicidal behavior in the post-partum. Our cross-sectional study targets a unique, understudied population in which the pronounced severity of symptoms required hospitalization. We analyzed plasma IL-1ß, IL-2, IL-6, IL-8, TNF-α, tryptophan, serotonin, kynurenine, nicotinamide, quinolinic- and kynurenic acids in post-partum women diagnosed with peripartum onset depression (PPD) and healthy controls (n = 165). We assessed depression severity using the Edinburgh Postnatal Depression Scale and suicidality using the Columbia-Suicide Severity Rating Scale. We found that increased plasma IL-6 and IL-8 and reductions of serotonin, IL-2 and quinolinic acid were associated with the severity of depressive symptoms and increased the risk for PPD. Moreover, women with lower serotonin levels were at an increased risk for suicidal behavior, even when adjusting for depression severity, psychosocial factors, age BMI, and medication. Our results indicate that severe depression in the post-partum involves dysregulation of the immune response and the kynurenine pathway, with a concomitant reduction in serotonin levels. We propose that inflammatory cytokines and the kynurenine pathway are potential treatment targets in PPD, opening up the possibility of novel therapeutic strategies targeting the peripartum.

The study protocol: Neuroendocrinology and (epi-) genetics of female reproductive transition phase mood disorder - an observational, longitudinal study from pregnancy to postpartum.

BACKGROUND: Postpartum depression is considered to be one of the most common health threats during pregnancy and postpartum, affecting not only the woman herself but also the offspring and the whole family system. Evidence for a conclusive etiopathological model with distinct risk and resilience factors is still broadly lacking. Therefore, the aim of the present study is to investigate numerous health-related markers to obtain greater insight into which biopsychosocial profiles render women more vulnerable to PPD or facilitate a healthy transition from pregnancy to postpartum. METHODS: The observational, longitudinal study aims to include a total of 288 physically healthy women, aged 20-45 years. A multitude of relevant parameters, of an (epi-) genetic, endocrinological, physiological and psychological nature, will be assessed over a period of 5 months, following the participants from the 3rd trimester until three months postpartum. DISCUSSION: The ultimate goal of the present study is to ameliorate mental health care during pregnancy and postpartum, by gaining a better understanding of the underlying biopsychosocial mechanisms that women undergo during the transition from pregnancy to postpartum.

Maternal Postpartum Diet and Postpartum Depression: A Systematic Review.

OBJECTIVES: Compelling evidence from observational studies shows that dietary patterns play a role in the development of depression and depressive symptoms in the general population. However, few studies have specifically sought to explore the association between maternal diet in the postpartum period and PPD. The purpose of this literature review was to synthesise data from existing published studies, examining the association between maternal postpartum diet and PPD symptoms. METHODS: Relevant studies were identified by systematic search from the Cochrane, MEDLINE, EMBASE, CINAHL, PubMed and PsycInfo databases for articles published between 1835 and April 2020. RESULTS: Of the 931 articles identified, six met eligibility criteria and were included. Four were cross-sectional and two were a cohort design. All but one study showed at least one inverse association, such that greater adherence to a healthy diet in the postpartum period was associated with fewer PPD symptoms. Specifically, if confirmed in further longitudinal and intervention studies, a balanced maternal diet with an emphasis on fruits, vegetables, fish, grains, legumes, and herbs could be a potential option for helping reduce the incidence of PPD. CONCLUSIONS: This review provides evidence that the postnatal diet could have an effect on PPD symptoms, although further longitudinal and intervention research is warranted.

Hair cortisol in pregnancy interacts with maternal depressive symptoms to predict maternal disrupted interaction with her infant at 4 months.

Disrupted maternal interaction in early infancy is associated with maladaptive child outcomes. Thus, identifying early risk factors for disrupted interaction is an important challenge. Research suggests that maternal depressive symptoms and maternal cortisol dysregulation are associated with disrupted maternal interaction, but both factors have rarely been considered together as independent or interactive predictors of disrupted interaction. In a sample of 51 women, hair cortisol concentrations (HCC) and depressive symptoms were assessed during pregnancy, and depressive symptoms were assessed again at 4-month postpartum. Maternal disrupted interaction was assessed during the Still-Face Paradigm at 4 months. Results indicated that HCC and depressive symptoms interacted to predict both maternal withdrawing and inappropriate/intrusive interaction. Withdrawing interaction was associated with high levels of HCC in pregnancy in the context of high depressive symptoms at 4 months; inappropriate/intrusive interaction was associated with high levels of HCC in the context of low depressive symptoms. Thus, high HCC potentiated both forms of disrupted interaction. Results raised questions about the meaning of very low reported depressive symptoms, and underscored the importance of chronic stress physiology and maternal depressed mood as risk factors for distinct forms of maternal disrupted interaction, both of which are deleterious for infant development.

A prospective study of maternal postnatal depressive symptoms with infant-feeding practices in a Chinese birth cohort.

BACKGROUND: The first few weeks after childbirth are critical, as women may encounter lactation problems and postpartum depression during this period. However, it is still unclear whether early breastfeeding behaviours are related to the symptoms of postnatal depression (PND) in Chinese populations. Therefore, the current study aimed to investigate the association between symptoms of PND and infant feeding practices based on a large-scale Chinese cohort. METHODS: A prospective study of the community-based cohort was conducted from January 2015 to December 2016. Infant feeding outcomes, including exclusive/partial breastfeeding and formula feeding, were assessed according to the WHO guidelines. Symptoms of PND were assessed by the Edinburgh Postnatal Depression Scale at 4 weeks postpartum. Multivariate generalized estimating equation models were applied to investigate the associations between depressive symptoms and infant feeding behaviours. RESULTS: A total of 956 mother-infant pairs were included. Fifty-six mothers presented screen-positive symptoms of PND with a cut-off ≥10. The percentage of early breastfeeding initiation was 75.8%, while the average duration of exclusive breastfeeding was 3.90 ± 2.33 months. Postnatal depressive symptoms were associated with a shorter breastfeeding duration (8.02 vs. 6.32 months, P < 0.05) and earlier formula introduction (4.98 vs. 3.60 months, P < 0.05). After adjustments were made for covariates, postnatal depressive symptoms were associated with an increased risk of the discontinuation of exclusive and partial breastfeeding (ß = - 0.049, P = 0.047 and ß = - 0.082, P = 0.006, respectively). Compared to mothers without symptoms of PND, mothers with depressive symptoms were more likely to supplement formula for their infants in the first year of life (ß =0.074, P = 0.016). These associations were still significant in the sensitivity analyses, using an EPDS cut-off of ≥13. CONCLUSIONS: Our findings indicate that depressive symptoms at 4 weeks postpartum are associated with the cessation of exclusive and partial breastfeeding duration and the introduction of formula in the 12 months of delivery. Early psychosocial assessment and social support should be offered to mothers in the early postpartum period to indirectly prevent adverse breastfeeding outcomes.

The maternal reward system in postpartum depression.

The experience of motherhood is most often emotionally positive and rewarding, but for many new mothers suffering from postpartum depression (PPD), this is not the case. Preclinical and clinical research has sought to uncover brain changes underlying PPD in order to gain a better understanding of how this disorder develops. This review focuses on the mesolimbic dopamine system, particularly the ventral tegmental area-nucleus accumbens pathway which has been implicated in the regulation of critical functions disrupted in PPD including mood, motivation, and mothering. Specifically, we discuss normative changes in the mesolimbic system during motherhood in both rodents and humans and how these are impacted in PPD. We also consider modulation of mesolimbic dopamine by the hypothalamic neuropeptide oxytocin and how oxytocin-dopamine interactions regulate mood and mothering during the postpartum period. In addition to providing an overview of reward mechanisms in PPD, our goal is to highlight open questions which warrant further research.

Maternal Stress and Mental Health Prior to Their Technology-Dependent Infant's Discharge Home From the NICU.

Mothers of infants in the neonatal intensive care unit (NICU) face stressors including turbulent emotions from their pregnancy/unexpected preterm delivery and their infant's unpredictable health status. The study purpose was to examine the psychological state of mothers prior to the discharge of their technology-dependent infants (eg, feeding tubes, supplemental oxygen) from the NICU to home. The study sample consisted of mothers (N = 19) of infants dependent on medical technology being discharged from a large Midwest NICU. A descriptive, correlational design using convenience sampling was employed to recruit mothers to examine associations of infant and maternal factors, resourcefulness, and stress with psychological state (depressive symptoms, posttraumatic stress symptoms). Forty-two percent of mothers were at high risk for clinical depression, with 37% in the clinical range for posttraumatic stress disorder. Increased maternal depressive symptoms were significantly associated with the increased frequency and perceived difficulty of their stress and posttraumatic stress symptoms. Increased posttraumatic stress symptoms were significantly associated solely with elevated depressive symptoms. This study identified factors associated with the mothers' increased psychological distress, providing beginning evidence for future interventions to employ prior to their technology-dependent infant's NICU discharge.

Physical Activity and the Occurrence of Postnatal Depression-A Systematic Review.

Background and Objectives: During pregnancy and the postnatal period many changes occur in a woman's body, both in mental and physical spheres. The birth of a child and a new role-of a mother-can sometimes be associated with numerous negative emotions, uncertainty, fear, anxiety, disgust, depression, or sadness. In the puerperium period, the development of baby blues or postpartum depression may occur. Postpartum depression develops within one month of childbirth and may last up to one year. Depressive disorders that may develop in a young mother affect both her and the newborn's health. That is why it is so important to try to search for factors that could significantly reduce the likelihood of developing depression in this period. The study aims at assessing the relationship between physical activity during pregnancy and puerperium or in the postpartum and the development of postnatal depression. Materials and Methods: A review of the literature was carried out in the Medline-PubMed database. The search terms were "pregnancy" AND "physical activity AND postpartum depression". The study included only English-language publications published in the period 2000-2018. Results: A total of 216 references were found. After establishing the inclusion and exclusion criteria based on the analysis of titles and abstracts, 173 articles were excluded from the review. A total of 43 publications were read in full. Finally, 16 articles were included in the review. It was shown that regular physical activity during pregnancy, pregnancy, and puerperium, or in the postnatal period itself as compared to inactivity, reduces the risk of developing depression in pregnant women and after the birth of a child. Conclusions: Physical activity can be an essential factor in the prevention of depressive disorders of women in the postnatal period.

Postpartum Depression: When the Stakes Are the Highest.

Pregnancy, a sensitive time when two bodies are changing and developing simultaneously, demands careful consideration in assessing and treating mental health conditions. Add to that the restrictions on researching such a vulnerable population, psychiatric nurses face a challenge in providing evidence-based care. The current article focuses on the epidemiology of postpartum depression and long-term consequences, neurobiology of postpartum depression that guides medication selection, and treatment options for supporting postpartum women and their families. [Journal of Psychosocial Nursing and Mental Health Services, 57(11), 9-14.].

Course of major depressive disorder after pregnancy and the postpartum period.

BACKGROUND: Maternal major depressive disorder (MDD) has an adverse effect on child development and increases risk for child psychopathology. It is paramount to understand the course of maternal depression during the childhood years particularly before, during, and after pregnancy. OBJECTIVE: To follow the course of MDD in women with prior histories of depression followed during an index pregnancy. METHODS: Subjects were women with histories of MDD who had participated in prior prospective, observational studies during pregnancy. In the follow-up, participants completed a structured interview that addressed (1) the course of MDD since their index pregnancy, (2) new psychiatric diagnoses, and (3) the course of MDD and treatment across subsequent pregnancies. RESULTS: Out of 129 eligible women, 48.8% participated (N = 63) with an average/mean time of 12.9 years (SD = 1.9, 8.8-16.7) elapsed since participation in the prior pregnancy studies. Although approximately one third reported sustained remission from MDD since the pregnancy during which they had been originally followed, of the remaining two thirds of women who reported subsequent depressive episodes, almost one fifth (∼12% of the total sample) endorsed depression more than 50% of the time following their index pregnancy. A total of 6.3% of the women with previous validated diagnoses of MDD reported new diagnoses of bipolar disorder. Women reported similar treatment choices regarding the use of antidepressants during pregnancies subsequent to the one followed in the previous study. CONCLUSION: Women with MDD experienced high rates of recurrent depression across the childbearing years. This represents a critical variable for clinical care and research.

A longitudinal study of women's depression symptom profiles during and after the postpartum phase.

BACKGROUND: An issue of critical importance for psychiatry and women's health is whether postpartum depression (PPD) represents a unique condition. The Diagnostic and Statistical Manual of Mental Disorders asserts that major depressive disorder (MDD) may present with peripartum onset, without suggesting any other differences between MDD and PPD. The absence of any distinct features calls into question the nosologic validity of PPD as a diagnostic category. The present study investigates whether symptom profiles differ between PPD and depression occurring outside the postpartum phase. METHODS: In a prospective, longitudinal study of parturient women (N = 239), we examine the manifestation of depression symptoms. We assess factor structure of symptom profiles, and whether factors are differentially pronounced during and after the postpartum period. RESULTS: Factors were revealed representing: Worry, Emotional/Circadian/Energetic Dysregulation, Somatic/Cognitive, Appetite, Distress Display, and Anger symptoms. The factor structure was validated at postpartum and after-postpartum timepoints. Interestingly, the Worry factor, comprising anxiety and guilt, was significantly more pronounced during the postpartum timepoint, and the Emotional/Circadian/Energetic Dysregulation factor, which contained sadness and anhedonia, was significantly less pronounced during the postpartum period. CONCLUSIONS: These results suggest that PPD may be a unique syndrome, necessitating research, diagnosis, and treatment strategies distinct from those for MDD. Results indicate the possibility that Worry is an enhanced feature of PPD compared to depression outside the postpartum period, and the crucial role of sadness/anhedonia in MDD diagnosis may be less applicable to PPD diagnosis.

Postpartum depression in older women.

Postpartum depression, which affects 10% to 20% of women in the United States, can significantly harm the health and quality of life for mother, child, and family. This article reviews the risk factors, pathophysiology, clinical manifestations, diagnosis, and treatment of postpartum depression with specific focus on women of advanced maternal age.

Rumination in dysphoric mothers negatively affects mother-infant interactions.

BACKGROUND: Postnatal maternal depressive symptoms are consistently associated with reduced quality of mother-infant interaction. However, there is little research examining the role of maternal cognitive factors (e.g. rumination) in the relationship between depressive symptoms and mother-infant interaction quality. This study investigated the hypotheses that: dysphoric mothers would demonstrate less sensitive behaviour towards their infants compared with nondysphoric mothers; mothers induced to ruminate would be less sensitive towards infants; rumination would moderate the relationship between maternal depressive symptoms and maternal sensitivity and the impact of the rumination induction would increase following a stressor (still face) task. METHOD: Mothers (N = 79; 39 dysphoric and 40 nondysphoric) and their infants were randomised to either a rumination induction or a control condition. Maternal sensitivity in mother-infant interactions was assessed before and after the induction using the CARE Index. In the second interaction task, mothers also completed the still-face procedure as a stressor. RESULTS: Extending previous research, mixed measures ANOVAs demonstrated that dysphoric mothers had reduced quality of interaction with their infant compared with nondysphoric mothers and that mothers in the rumination condition exhibited reduced sensitivity towards their infants relative to mothers in the control condition. Further, maternal sensitivity worsened further after the still-face procedure in the rumination condition, but not in the control condition. CONCLUSIONS: This study suggests that the repetitive, internal focus of a ruminative state is causally implicated in mother-infant interaction quality, regardless of the level of depressive symptoms. This research extends understanding of specific mechanisms involved in the quality of the mother-infant relationship.