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.

Maternal Mental Health MATTERS.

Depression and anxiety during pregnancy and the postpartum period are common and have significant negative impacts on mother and child. Suicide is a leading cause of maternal mortality. Evidence-based efforts for screening, assessment, and treatment improve maternal and infant mental health, as well as overall family health, throughout the lives of women and children.

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.

A role for the microbiome in mother-infant interaction and perinatal depression.

Perinatal depression is a significant public health problem, due to its negative impact on maternal well-being and long-term adverse effects for children. Mother-infant interaction and maternal responsiveness and sensitivity are a hypothesized mechanism by which perinatal depression effects child development, and increasing research in the microbiota-gut-brain axis may provide a new avenue of investigation. There is limited efficacy for treatment of perinatal depression for improving the mother-infant relationship and child outcomes. The maternal microbiota may be the basis of child outcomes through foetal programming and sharing of microbes between mother and infant. There is evidence that less diversity of the intestinal microbial community is associated with neuropsychiatric disorders, including depression and anxiety in mothers and offspring. Assessing the maternal and child's microbial communities may be an important missing component in mother-infant attachment-based therapies during treatment of perinatal depression. Probiotics and prebiotics require further research as additions to mother-infant interventions. Further research may enable identification of bacterial genes that indicate specific pathways that could be targeted to improve outcomes for mother and child.

Beyond screening: a review of pediatric primary care models to address maternal depression.

Depression is one of the most debilitating chronic disorders in the United States, affecting 15 million children in homes with depressed mothers, many of whom endure household chaos, inconsistent nurturing, inadequate safety practices, and harsh discipline. Depressed mothers are under diagnosed and undertreated, yet there is broad consensus about the importance of identifying and managing maternal depression, as reflected in recommendations by pediatric and obstetric professional organizations to routinely screen for perinatal depression. Screening was shown to be acceptable to women and most pediatric providers, and adding a screening component need not impair clinic efficiency. Screening, however, is not sufficient, and there are few models in the literature to guide medical practices in implementing successful interventions to identify, treat, and prevent maternal depression, particularly in the pediatric setting. We reviewed the literature and identified six studies that evaluated models for screening and managing mothers' depression in pediatric primary care settings. Some of these interventions have promise, but no studies characterized health outcomes of the depressed mothers and children. We discuss the components of these models, their implementation, and the practice and research needed to create effective pediatrics-based systems to reduce the negative effects of maternal depression on mothers, children, and families.

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.

Family history, not lack of medication use, is associated with the development of postpartum depression in a high-risk sample.

We sought to determine clinical predictors of postpartum depression (PPD), including the role of medication, in a sample of women followed prospectively during and after pregnancy. Women with a history of mood disorder were recruited and evaluated during each trimester and 1 week, 1 month, and 3 months postpartum. DSM-IV criteria for a major depressive episode were assessed by a psychiatric interview at each time point. Sixty-three women with major depression and 30 women with bipolar disorder entered the study and 75.4 % met DSM-IV criteria for a MDE during pregnancy, postpartum, or both. We modeled depression in a given time period (second trimester, third trimester, or 1 month postpartum) as a function of medication use during the preceding period (first, second, or third trimester). The odds of being depressed for those who did not use medication in the previous period was approximately 2.8 times that of those who used medication (OR 2.79, 95 % CI 1.38-5.66, p = 0.0048). Of 38 subjects who were psychiatrically well during the third trimester, 39.5 % (N = 15) met the criteria for a MDE by 4 weeks postpartum. In women who developed PPD, there was a high rate of a family history of PPD (53.3 %) compared to women who did not develop PPD (11.8 %, p = 0.02). While the use of psychiatric medications during pregnancy reduced the odds of being depressed overall, the use of psychiatric medications during pregnancy may not protect against PPD in women at high risk, particularly those with a family history of PPD.

The importance of social support for women with elevated anxiety undergoing care for gynecologic malignancies.

OBJECTIVES: The aim of this study was to screen for depression and anxiety and to assess well-being among women diagnosed with gynecologic malignancies, identify factors associated with elevated depressive or anxiety symptoms, and further characterize the needs of those with elevated anxiety or depressive symptoms. METHODS/MATERIALS: Women presenting for gynecologic cancer at an academic center during the course of 10 months were offered screening for depressive and anxiety symptoms. Patients were screened with the Primary Care Evaluation of Mental Disorders' Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7. The Functional Assessment of Cancer Therapy-General assessed well-being. Demographics, psychiatric history, and components about the cancer and treatment were collected. Those who screened positive with scores of 10 or higher on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 were offered a meeting with the study psychiatrist for further evaluation both with the Structured Clinical Interview for Diagnosis as well as with an interview to discuss their experiences and to assess their desired needs. RESULTS: When family and social well-being was added to the logistic regression model, higher family and social well-being was the strongest factor associated with lower amounts of anxiety (odds ratio, 0.10; P = 0.001 for a cutoff of 10; odds ratio, 0.21; P = 0.012 for a cutoff of 8). Less than 30% who screened positive met with the study psychiatrist and were not receiving optimal treatment. CONCLUSIONS: Given that low family and social well-being and elevated anxiety symptoms were so highly correlated, those with anxiety symptoms would most benefit from social interventions. However, this study also found that patients with elevated depressive or anxiety symptoms were difficult to engage with a psychiatric provider. We need partnership between psychiatry and gynecology oncology to identify those with elevated depressive and anxiety symptoms and develop better ways to provide psychosocial supports.

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.

Investigating heart rate variability measures during pregnancy as predictors of postpartum depression and anxiety: an exploratory study.

Perinatal affective disorders are common, but standard screening measures reliant on subjective self-reports might not be sufficient to identify pregnant women at-risk for developing postpartum depression and anxiety. Lower heart rate variability (HRV) has been shown to be associated with affective disorders. The current exploratory study aimed to evaluate the predictive utility of late pregnancy HRV measurements of postpartum affective symptoms. A subset of participants from the BASIC study (Uppsala, Sweden) took part in a sub-study at pregnancy week 38 where HRV was measured before and after a mild stressor (n = 122). Outcome measures were 6-week postpartum depression and anxiety symptoms as quantified by the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Anxiety Inventory (BAI). In total, 112 women were included in a depression outcome analysis and 106 women were included in an anxiety outcome analysis. Group comparisons indicated that lower pregnancy HRV was associated with depressive or anxious symptomatology at 6 weeks postpartum. Elastic net logistic regression analyses indicated that HRV indices alone were not predictive of postpartum depression or anxiety outcomes, but HRV indices were selected as predictors in a combined model with background and pregnancy variables. ROC curves for the combined models gave an area under the curve (AUC) of 0.93 for the depression outcome and an AUC of 0.83 for the anxiety outcome. HRV indices predictive of postpartum depression generally differed from those predictive of postpartum anxiety. HRV indices did not significantly improve prediction models comprised of psychological measures only in women with pregnancy depression or anxiety.

Benefits of maternally-administered infant massage for mothers of hospitalized preterm infants: a scoping review.

OBJECTIVES: Infant massage (IM) is a well-studied, safe intervention known to benefit infants born preterm. Less is known about the benefits of maternally-administrated infant massage for mothers of preterm infants who often experience increased rates of anxiety and depression in their infants' first year of life. This scoping review summarizes the extent, nature, and type of evidence linking IM and parent-centered outcomes. METHODS: The Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for scoping reviews (PRISMA-ScR) protocol was followed using three databases: PubMed, Embase, and CINAHL. Thirteen manuscripts evaluating 11 separate study cohorts met pre-specified inclusion criteria. RESULTS: Six primary topics related to the influence of infant massage on parent outcomes emerged: 1) anxiety, 2) perceived stress, 3) depressive symptoms, 4) maternal-infant interaction, 5) maternal satisfaction, and 6) maternal competence. Emerging evidence supports that infant massage, when administered by mothers, benefits mothers of preterm infants by reducing anxiety, stress, and depressive symptoms and improving maternal-infant interactions in the short-term, but there is limited evidence to support its effectiveness on these outcomes in longer periods of follow-up. Based on effect size calculations in small study cohorts, maternally-administered IM may have a moderate to large effect size on maternal perceived stress and depressive symptoms. CONCLUSIONS: Maternally-administered IM may benefit mothers of preterm infants by reducing anxiety, stress, depressive symptoms, and by improving maternal-infant interactions in the short-term. Additional research with larger cohorts and robust design is needed to understand the potential relationship between IM and parental outcomes.

Interactions between perceived stress and microbial-host immune components: two demographically and geographically distinct pregnancy cohorts.

Higher stress during pregnancy associates with negative outcomes and elevated inflammation. The gut microbiota, reflecting environment and social interactions, alongside host immune responses have the potential to better understand perceived stress and identify when stress is excessive in pregnancy. Two U.S. cohorts of 84 pregnant individuals, composed of urban women of color and suburban white women, completed the Perceived Stress Scale-10 (PSS-10) and provided fecal and blood samples at two time points. Confirmatory Factor Analysis assessed the robustness of a two-factor PSS-10 model (Emotional Distress/ED and Self-Efficacy/SE). Gut microbiota composition was measured by 16 S rRNA amplicon sequencing and the immune system activity was assessed with a panel of 21 T-cell related cytokines and chemokines. ED levels were higher in the suburban compared to the urban cohort, but levels of SE were similar. ED and SE levels were associated with distinct taxonomical signatures and the gut microbiota data improved the prediction of SE levels compared with models based on socio-demographic characteristics alone. Integration of self-reported symptoms, microbial and immune information revealed a possible mediation effect of Bacteroides uniformis between the immune system (through CXCL11) and SE. The study identified links between distinct taxonomical and immunological signatures with perceived stress. The data are congruent with a model where gut microbiome and immune factors, both impacting and reflecting factors such as close social relationships and dietary fiber, may modulate neural plasticity resulting in increased SE during pregnancy. The predictive value of these peripheral markers merit further study.

A Brexanolone Treatment Program at an Academic Medical Center: Patient Selection, 90-Day Posttreatment Outcomes, and Lessons Learned.

BACKGROUND: Brexanolone is the first U.S. Food and Drug Administration-approved drug for the treatment of postpartum depression. Brexanolone is a positive allosteric modulator of the GABAA receptor and is given over 60 hours by infusion in a medical setting. This drug has been shown to be effective at significantly reducing Hamilton Rating Scale for Depression scores at 60 hours and 30 days after infusion; however, data beyond 30 days have not yet been available. There have been limited clinical programs able to offer brexanolone owing to the complexity of setting up this treatment in a medical setting. PURPOSE: This study sought to obtain follow-up data from 16 patients who received a brexanolone infusion at UNC Hospitals in Chapel Hill, NC, between October 2019 and December 2020 and were beyond the 30-day postinfusion time point. We describe the methods used to successfully implement this treatment program in an academic medical center and discuss associated challenges and lessons learned with patient selection and process improvements. METHODS: Hamilton Rating Scale for Depression scores were collected before and after infusion from 16 patients who received a brexanolone infusion at UNC. Patients were subsequently contacted for a follow-up interview to obtain Hamilton Rating Scale for Depression scores and complete a semistructured interview at least 30 days past treatment end (between 3 and 16 months after infusion). RESULTS: All 16 patients had a significant reduction in Hamilton Rating Scale for Depression scores at 60 hours, scores dropping on average from 23.9 (standard deviation = 2.6) to 7.6 (standard deviation = 2.9). Eleven of 16 patients consented to provide follow-up data. Follow-up Hamilton Rating Scale for Depression scores remained lower than postinfusion at an average of 6.7 points (standard deviation = 5.1). CONCLUSION: With a strategic cross-disciplinary approach, a Clinical Brexanolone Treatment Program was established at UNC Hospitals in 2019. Sixteen patients have been treated in the program, and 11 participated in a follow-up interview. All 11 patients gave very positive feedback about their treatment. Our program has found brexanolone to be a useful clinical tool in treating women with significant symptoms of postpartum depression.

Differentiated mental health patterns in pregnancy during COVID-19 first two waves in Sweden: a mixed methods study using digital phenotyping.

To utilize modern tools to assess depressive and anxiety symptoms, wellbeing and life conditions in pregnant women during the first two waves of the COVID-19 pandemic in Sweden. Pregnant women (n = 1577) were recruited through the mobile application Mom2B. Symptoms of depression, anxiety and wellbeing were assessed during January 2020-February 2021. Movement data was collected using the phone's sensor. Data on Google search volumes for "Corona" and Covid-related deaths were obtained. Qualitative analysis of free text responses regarding maternity care was performed. Two peaks were seen for depressive symptoms, corresponding to the two waves. Higher prevalence of anxiety was only noted during the first wave. A moderating effect of the two waves in the association of depression, anxiety, and well-being with Covid deaths was noted; positive associations during the first wave and attenuated or became negative during the second wave. Throughout, women reported on cancelled healthcare appointments and worry about partners not being allowed in hospital. The association of mental health outcomes with relevant covariates may vary during the different phases in a pandemic, possibly due to adaptation strategies on a personal and societal/healthcare level. Digital phenotyping can help healthcare providers and governmental bodies to in real time monitor high-risk groups during crises, and to adjust the support offered.