The Pressing Need to Integrate Mental Health into Obstetric Care.

Mental health and substance use conditions are prevalent among perinatal individuals. These conditions have a negative impact on the health of perinatal individuals, their infants, and families, yet are underdiagnosed and undertreated. Populations that have been marginalized disproportionately face barriers to accessing care. Integrating mental health into obstetric care could address the perinatal mental health crisis. We review perinatal mental health conditions and substance use, outline the impact associated with these conditions, and describe the promise and potential of integrating mental health into obstetric settings to improve outcomes for patients receiving obstetric and gynecologic care.

Implementation of a Hospital-based Brexanolone Program.

Postpartum depression (PPD) is a serious complication of childbearing affecting ∼1 in 7 mothers. Left unrecognized and untreated, it is associated with negative outcomes for mothers and their infants. Building upon research suggesting that, for some women, hormonal fluctuations after childbirth contribute to the onset of depression, clinical trials have found promise in a novel treatment approach, brexanolone infusion. In 2019, the Food and Drug Administration (FDA) approved brexanolone as the first medication with an indication specifically for PPD. Delivering brexanolone treatment to patients in need requires overcoming some logistical and clinical challenges that are unique to this approach. This brief report describes the process by which a university-affiliated obstetric-gynecologic hospital in the northeast United States successfully implemented a program to administer this novel treatment to women with PPD.

Father's Perspectives on Family Relationships and Mental Health Treatment Participation in the Context of Maternal Postpartum Depression.

Objective: To understand the perspectives of fathers whose partners experienced postpartum depression, particularly (1) views on how fathers and family relationships were impacted by maternal PPD, and (2) attitudes regarding inclusion of fathers within the treatment process. Methods: We conducted qualitative interviews with 8 postpartum couples using a semi-structured protocol, and administered questionnaires assessing demographics, depression, and family functioning. We abstracted data from hospital records regarding the mother's depressive episode. We summarized quantitative data using descriptive statistics, and analyzed interview transcripts using qualitative analysis techniques, focusing specifically on fathers' input on postpartum relationships and treatment involvement. Results: Over one-third of fathers had elevated symptoms of depression, and family functioning scores suggested that most couples were experiencing dysfunction in their relationships. Qualitative analysis identified three major categories of themes, and subthemes in each category. Major themes included: (1) fathers' experiences during the postpartum period, including not understanding postpartum mental health conditions and desiring more information, experiencing a range of emotions, and difficulty of balancing work with family; (2) fathers' views on postpartum relationships, such as communication problems, empathy for partner, and relationship issues with other family members; (3) fathers' attitudes toward postpartum treatment, including openness to be involved, perceived benefits, and barriers and facilitators to the inclusion of partners in treatment. Conclusion: Though barriers exist, many fathers are motivated to be included in the treatment process. In addition to supporting maternal wellbeing, fathers view treatment as a means to improve issues in the couple or family system, such as communication difficulties.

Author Correction: Metabolic and Addiction Indices in Patients on Opioid Agonist Medication-Assisted Treatment: A Comparison of Buprenorphine and Methadone.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Metabolic and Addiction Indices in Patients on Opioid Agonist Medication-Assisted Treatment: A Comparison of Buprenorphine and Methadone.

Metabolic hormones stabilize brain reward and motivational circuits, whereas excessive opioid consumption counteracts this effect and may impair metabolic function. Here we addressed the role of metabolic processes in the course of the agonist medication-assisted treatment for opioid use disorder (OUD) with buprenorphine or methadone. Plasma lipids, hemoglobin A1C, body composition, the oral glucose tolerance test (oGTT) and the Sweet Taste Test (STT) were measured in buprenorphine- (n = 26) or methadone (n = 32)- treated subjects with OUD. On the whole, the subjects in both groups were overweight or obese and insulin resistant; they displayed similar oGTT and STT performance. As compared to methadone-treated subjects, those on buprenorphine had significantly lower rates of metabolic syndrome (MetS) along with better values of the high-density lipoproteins (HDL). Subjects with- vs. without MetS tended to have greater addiction severity. Correlative analyses revealed that more buprenorphine exposure duration was associated with better HDL and opioid craving values. In contrast, more methadone exposure duration was associated with worse triglycerides-, HDL-, blood pressure-, fasting glucose- and hemoglobin A1C values. Buprenorphine appears to produce beneficial HDL- and craving effects and, contrary to methadone, its role in the metabolic derangements is not obvious. Our data call for further research aimed at understanding the distinctive features of buprenorphine metabolic effects vis-à-vis those of methadone and their potential role in these drugs' unique therapeutic profiles.

Peripartum depression: Early recognition improves outcomes.

Depression is highly prevalent in women of childbearing age, especially during the postpartum period. Early recognition and treatment improve outcomes for mother, developing fetus, and infant. Caution is warranted when prescribing antidepressants to pregnant and breastfeeding mothers, but evidence is mounting that the risks of untreated maternal depression outweigh those of pharmacologic treatment for it.

Co-occurring Disordered Gambling Among Treatment-Seekers at a Community Outpatient Addiction Clinic.

BACKGROUND: Parallel to the ongoing expansion of legalized gambling activities is a growing concern about rising occurrence of uncontrollable gambling. People with preexisting gambling and/or chemical addictions may be particularly vulnerable, but the extent of such co-occurring conditions and their demographic and clinical characteristics have not been sufficiently elucidated. To that end, the present study attempted to both, quantify the presence and to characterize co-occurring pathological or problem gambling (ie, respectively, at least 1- or at least 5 pathological gambling criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) among treatment-seeking patients at a community outpatient addiction program. METHODS: The patients were assessed with the South Oaks Gambling Screen and their charts were reviewed for the extraction of demographic and clinical information according to a predetermined template. Data from 183 subjects withstood quality control procedures and were included. RESULTS: The prevalence rates of co-occurring problem- (18.6%) and pathological (10.9%) gambling were strikingly higher than those found in the general population (2% and 0.5%, respectively). No increase in the clinical severity indices was observed across the gambling groups. CONCLUSIONS: Our data replicate those of prior studies reporting heightened prevalence of problematic gambling in patients with substance use disorders and extend the prior findings by including a subject population of treatment-seekers. In the era of the gambling industry growth, these results call for creation and/or adjustment of clinical addiction services to meet emerging preventive and therapeutic needs.

Clinical correlates of perinatal bipolar disorder in an interdisciplinary obstetrical hospital setting.

BACKGROUND: Pregnancy and the postpartum period can be destabilizing for women with bipolar disorder (BD), and treatment decisions particularly complex. Yet, to date, relatively little research has focused on perinatal BD. METHOD: Following IRB approval, trained raters reviewed clinical records of 334 women who had sought treatment at a specialized partial hospitalization program serving perinatal women, including demographic, clinical, and treatment history information as noted in each patient׳s chart by treating providers. RESULTS: Slightly over 10% of the perinatal sample was diagnosed with Bipolar I, Bipolar II, or Bipolar NOS Disorder. In addition, 26% of the sample, regardless of diagnostic status, reported recent, abnormally elevated mood persisting 4 or more days. Compared to women with other Axis I disorders, women with a BD diagnosis were more likely to report a substance abuse history, prior suicide attempts, and more extensive psychiatric histories, including greater use of pharmacotherapy. Pregnant women with BD were more likely to take psychotropic medications prenatally, and postpartum women with BD reported higher rates of birth complications and difficulty breastfeeding. LIMITATIONS: This research is limited by use of retrospective data, and utilization of self-report and clinician diagnosis, rather than structured interviews. CONCLUSION: Even in the context of a partial hospital sample with high levels of symptoms and impairment, the clinical features of perinatal women with BD stand out as markedly more severe in comparison to those of women seeking care for other perinatal psychiatric conditions. Risk for suicide, substance abuse, and difficulties in the mother-child relationship are concerns.

Correlates of impaired mother-infant bonding in a partial hospital program for perinatal women.

Maternal psychopathology is a risk factor for impaired mother-infant bonding, but not all women with this illness experience impaired bonding. This study investigated correlates of mother-infant bonding among 180 postpartum women treated in a psychiatric partial hospitalization program. Women completed self-report measures of depressive symptoms and mother-infant bonding, and a retrospective chart review assessed demographic characteristics, clinician-rated diagnoses, and obstetric factors. Symptoms of depression, self-reported suicidality, demographic characteristics, and mode of delivery were significantly associated with impaired bonding.

Symptoms of the anxiety disorders in a perinatal psychiatric sample: a chart review.

Symptoms of anxiety are a central feature of perinatal mental health, yet the anxiety disorders have received considerably less attention than depression in both perinatal research and practice. The present investigation involved a retrospective review of the clinical records of 334 patients seen at a psychiatric day hospital program serving pregnant and postpartum women. We examined the frequency with which the patients in this setting reported symptoms of anxiety, clinical correlates of elevated anxiety, and patterns of diagnosis in the clinical record. The results suggest that anxiety symptoms are very common in this population and that the presence of anxiety is associated with a more severe clinical profile, including higher rates of suicidality and increased use of psychotropic medications during pregnancy and postpartum. Although anxiety symptom levels were markedly elevated in this sample, anxiety disorders were diagnosed at relatively low rates. Implications for clinical practice, including discharge and treatment planning, are discussed.

A mother-baby psychiatric day hospital: History, rationale, and why perinatal mental health is important for obstetric medicine.

BACKGROUND: Women frequently experience depression, anxiety, or other mental health concerns during pregnancy and postpartum, impacting her and her infant's health. Patients who require management of medical conditions during the perinatal period are even more likely to experience depression and anxiety compared to those without comorbid medical issues. Despite the availability of effective treatments, perinatal mental health utilization rates are strikingly low. METHODS: To address common treatment barriers, we developed a specialized mother-baby day hospital for women with psychiatric distress during the peripartum. In this report, we summarize findings from 800 patient satisfaction surveys collected from women treated at the program between 2007 and 2012. RESULTS: Findings suggest that women are highly satisfied with the treatment received, often noting that the inclusion of the baby in their treatment is a highly valued feature of care. CONCLUSION: The relevance of perinatal mental health services for patients who are followed by obstetrical medicine specialists is discussed.

Psychological/verbal abuse and utilization of mental health care in perinatal women seeking treatment for depression.

Research on psychological violence has suggested it is common among perinatal women and is predictive of later physical violence. Psychological violence is also a strong correlate of negative mental and physical health outcomes and may influence engagement in health services. Both physical and mental health care are of critical importance for perinatal women who may be especially vulnerable to psychological violence and its deleterious effects. This study examined the clinical records of 299 perinatal patients who received treatment in a psychiatric partial hospital program to determine whether there were differences in utilization of care between those women with and without current interpersonal psychological abuse. More women than expected who reported current psychological abuse left treatment early compared to those without such reports.

Postpartum depression.

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.

Depression and breastfeeding: which postpartum patients take antidepressant medications?

Depressed breastfeeding women may have concerns about taking antidepressant medications due to fears regarding infant exposure. We examined the clinical records of 73 breastfeeding women who sought depression treatment, to identify characteristics of those who took antidepressants. Compared to women who were not treated with pharmacotherapy, breastfeeding patients who took antidepressants had more severe symptoms, greater functional impairment, more extensive psychiatric histories, and were less likely to be involved in a committed relationship. No differences were found in age, race, or education.

A preventive intervention for pregnant women on public assistance at risk for postpartum depression.

OBJECTIVE: Promising results were obtained in an earlier pilot study of a preventive intervention based on the principles of interpersonal psychotherapy to reduce the risk of postpartum major depressive disorder. In this study, the authors examined whether the intervention would reduce the risk of postpartum major depressive disorder in a larger sample of pregnant women. METHOD: Ninety-nine pregnant women on public assistance who were assessed to be at risk for postpartum depression were randomly assigned to receive standard antenatal care plus the intervention or standard antenatal care only. Diagnostic interviews were administered 3 months after delivery to assess for major depressive disorder. RESULTS: Within 3 months after delivery, eight (20%) of the women in the standard antenatal care condition had developed postpartum major depressive disorder, compared with two (4%) in the intervention condition. CONCLUSIONS: This study provides further evidence for the efficacy of a brief intervention to reduce the occurrence of major depressive disorder among financially disadvantaged women during a postpartum period of 3 months.

Clinical characteristics of perinatal psychiatric patients: a chart review study.

Although postpartum depression and other perinatal disorders have been the subject of increased research attention, important questions remain regarding women who actively seek psychiatric treatment during pregnancy and the postpartum period. In this study, we examined clinical records of 500 perinatal psychiatric patients who received treatment in a psychiatric day hospital (N = 398) or outpatient behavioral health clinic (N = 102). Patients' presenting diagnoses, psychiatric history, treatment course, and depressive symptoms were recorded. The majority of women had major depression as their primary diagnosis, with an average Edinburgh Postnatal Depression Scale score of over 20. Many depressed patients were diagnosed with comorbid anxiety and substance abuse disorders. Although most women were willing to take psychotropic medications, a sizable minority were not, particularly those who were breast-feeding. For more than a third of the sample, the treatment sought while pregnant or postpartum represented their first contact with the mental health system. Treatment implications are discussed.