Preconception depression and anxiety symptoms and maternal-infant bonding: a 20-year intergenerational cohort study.

Early maternal-infant bonding problems are often forerunners of later emotional and behavioural difficulties. Interventions typically target the perinatal period but many risks may be established well before pregnancy. Here we examine the extent to which adolescent and young adult depression and anxiety symptoms predict perinatal maternal-infant bonding difficulties. The Victorian Intergenerational Health Cohort Study (VIHCS, est. 2006) is following offspring born to the Victorian Adolescent Health Cohort Study (VAHCS; est. 1992). VAHCS participants were assessed for depression and anxiety symptoms nine times during adolescence and young adulthood (age 14-29 years), and then contacted bi-annually (from age 29-35 years) to identify pregnancies. The Postpartum Bonding Questionnaire (PBQ) was administered to mothers at 2 and 12 months postpartum. A total of 395 women (606 infants) completed the 2-month and/or 12-month postpartum interviews. For most infants (64%), mothers had experienced depression and/or anxiety before pregnancy. Preconception depression and anxiety symptoms that persisted from adolescence into young adulthood predicted maternal-infant bonding problems at 2 months (ß = 0.30, 95% CI 0.04, 0.55) and 12 months postpartum (ß = 0.40, 95% CI 0.16, 0.63). Depression and anxiety symptoms occurring in young adulthood only, also predicted bonding problems at 12 months postpartum (ß = 0.37, 95% CI 0.02, 0.71). Associations between preconception depression and anxiety symptoms and anxiety-related maternal-infant bonding problems at 12 months postpartum remained after adjustment for antenatal and concurrent postpartum depressive symptoms. This study puts forward a case for extending preconception health care beyond contraception and nutrition to a broader engagement in supporting the mental health of young women from adolescence.

The Victorian Intergenerational Health Cohort Study (VIHCS): Study design of a preconception cohort from parent adolescence to offspring childhood.

BACKGROUND: There is increasing evidence that parental determinants of offspring early life development begin well before pregnancy. OBJECTIVES: We established the Victorian Intergenerational Health Cohort Study (VIHCS) to examine the contributions of parental mental health, substance use, and socio-economic characteristics before pregnancy to child emotional, physical, social, and cognitive development. POPULATION: Men and women were recruited from the Victorian Adolescent Health Cohort (VAHCS), an existing cohort study beginning in 1992 that assessed a representative sample of 1943 secondary school students in Victoria, Australia, repeatedly from adolescence (wave 1, mean age 14 years) to adulthood (wave 10, mean age 35 years). METHODS: Victorian Adolescent Health Cohort participants with children born between 2006 and 2013 were recruited to VIHCS and invited to participate during trimester three, at 2 months postpartum, and 1 year postpartum. Parental mental health, substance use and socio-economic characteristics were assessed repeatedly throughout; infant characteristics were assessed postnatally and in infancy. Data will be supplemented by linkage to routine datasets. A further follow-up is underway as children reach 8 years of age. PRELIMINARY RESULTS: Of the 1307 infants born to VAHCS participants between 2006 and 2013, 1030 were recruited to VIHCS. At VIHCS study entry, 18% of recruited parents had preconception common mental disorder in adolescence and young adulthood, 18% smoked daily in adolescence and young adulthood, and 6% had not completed high school. Half of VIHCS infants were female (48%), 4% were from multiple births, and 7% were preterm (<37 weeks' gestation). CONCLUSIONS: Victorian Intergenerational Health Cohort Study is a prospective cohort of 1030 children with up to nine waves of preconception parental data and three waves of perinatal parental and infant data. These will allow examination of continuities of parental health and health risks from the decades before pregnancy to offspring childhood, and the contributions of exposures before pregnancy to offspring outcomes in childhood.

Factors Associated With Response to Adapted Cognitive Behavioral Therapy for Anxiety and Depression Following Traumatic Brain Injury.

BACKGROUND: Given the high frequency and significance of anxiety and depression following traumatic brain injury (TBI), there is a need to evaluate the efficacy of psychological interventions and to understand factors influencing response to such interventions. The present study investigated factors associated with positive response to cognitive behavioral therapy adapted for cognitive impairments (CBT-ABI) for individuals with anxiety and depression following TBI, including demographic and injury-related factors, pretreatment levels of anxiety and depression, working alliance, and change expectancy as predictors. METHODS: Participants were 45 individuals enrolled in an active treatment condition within a randomized controlled trial, examining the efficacy of a 9-session CBT-ABI program for anxiety and depression following TBI. These participants completed all CBT sessions. RESULTS: Mixed-effects regressions controlling for baseline anxiety and depression indicated that for anxiety, older age at injury, as well as higher level of baseline anxiety, was associated with greater symptom reduction. For depression, longer time since injury and higher expectancy for change, as well as higher baseline level of depression, were significantly associated with a greater reduction in depression symptoms. CONCLUSIONS: This study paves the way for more detailed studies of the therapeutic processes involved in alleviating anxiety and depression following TBI.

Epidemiology and Natural History of Psychiatric Disorders After TBI.

This article outlines the epidemiology of psychiatric disorders in individuals with traumatic brain injury (TBI), with a focus on DSM axis I disorders diagnosed on the basis of structured clinical interview. The epidemiology of psychiatric disorders in the general population is described as a basis for understanding the disorders that occur before and after TBI. For each disorder category, including mood disorders, anxiety disorders, acute stress disorder, posttraumatic stress disorder (PTSD), substance use disorders, psychotic disorders, eating disorders, somatoform disorders, and adjustment disorders, the evidence from retrospective, cross-sectional and prospective studies is reviewed, showing the frequency, time course, and predictors of the disorders. Studies show elevated rates of depressive and anxiety disorders after TBI, most commonly major depressive disorder and PTSD, usually emerging in the first year postinjury but with delayed onset in severe injury cases. Although individuals with a preinjury history are more likely to develop these disorders, the nature of the disorders may change after injury, and novel psychiatric disorders are also common. Even though the frequency of anxiety disorders diminishes over the years postinjury, depressive disorders are more persistent during postinjury years. Substance use-while high before injury-declines after injury. The frequency of psychotic, eating, somatoform, and adjustment disorders do not exceed population rates.

The parental bonds of adolescent girls and next-generation maternal-infant bonding: findings from the Victorian Intergenerational Health Cohort Study.

The purpose of this study was to examine the extent to which adolescent bonding problems with parents predict next-generation maternal-infant bonding problems at 2 and 12 months postpartum. Data were from a two-generation prospective cohort study of 1026 offspring (3 perinatal waves) born to participants of a two-decade (10-wave) study of 1943 adolescents. Dyads in this analysis were 395 mothers (29-36 years) of 606 offspring (305 female). At 16 years, we assessed adolescents' perceptions of their mother's and father's care and control, separately and in combination. Subsequently, when participants were adult mothers of infants 2 and 12 months postpartum, we assessed impaired maternal-infant bonding, infant-directed rejection-anger, and caregiving anxiety. Adolescent-parent bonding problems were strongly predictive of women's subsequent bonding problems with infants. In particular, impaired postpartum maternal bonding was predicted by adolescent reports of low paternal care (12 months: OR=3.1, 95% CI 1.1-8.6) and high maternal control (12 months: OR=3.7, 95% CI 1.4-9.7). In combination, high maternal control and low paternal control also predicted impaired postpartum bonding (2 months: OR=5.0, 95% CI 1.3-20; 12 months: OR=12, 2.6-56), caregiving anxiety (2 months: OR=4, 95% CI 1.5-11; 12 months: OR=8.8, 95% CI 1.8-43), and rejection/anger (12 months: OR=4.1, 95% CI 1.0-16). Further combinations of care and overprotection that significantly predicted postpartum bonding problems are presented. Our results indicate that adolescent girls who experience high maternal control and low paternal care are at higher risk for subsequent maternal-infant bonding problems. The strength of associations suggests that interventions should begin well before pregnancy.

Disrupted White Matter Microstructure and Mood Disorders after Traumatic Brain Injury.

Traumatic brain injury (TBI) is associated with an elevated frequency of mood disorders that may, in part, be explained by changes in white-matter microstructure. This study is the first to examine the relationship between mood disorders and white-matter pathology in a sample of patients with mild to severe TBI using a standardized psychiatric interview. This study reports on a sub-sample of 29 individuals recruited from a large prospective study that examined the evolution of psychiatric disorders following complicated, mild to severe TBI. Individuals with TBI were also compared with 23 healthy control participants. Individuals were invited to complete the Structured Clinical Interview for DSM-IV Disorders (SCID) to diagnose psychiatric disorders. Participants who developed a mood disorder within the first 3 years were categorized into a TBI-Mood group. Diffusion tensor tractography assessed white matter microstructure using atlas-based tract-averaged and along-tract approaches. Fractional anisotropy (FA) was used as the measure of white-matter microstructure. TBI participants with and without a mood disorder did not differ in regard to injury severity and other background factors. Nevertheless, TBI participants diagnosed with a mood disorder displayed significantly lower tract-averaged FA values for the right arcuate fasciculus (p = 0.011), right inferior longitudinal fasciculus (p = 0.009), and anterior segments I (p = 0.0004) and II (p = 0.007) of the corpus callosum, as well as the left (p = 0.014) and right (p = 0.015) fronto-occipital longitudinal fasciculi. The pattern of white matter disruption identified in the current study provides further support for a neurobiological basis of post-TBI mood disorders. Greater understanding of individuals' underlying neuropathology may enable better characterization and prediction of mood disorders. Integration of neuropathology may also inform the potential efficacy of pharmacological and psychological interventions.

The relationship between family expressed emotion, perceived criticism and criticism sensitivity and psychiatric outcomes following traumatic brain injury.

Family expressed emotion (EE) is a strong predictor of outcome in a range of psychiatric and medical conditions. This study aimed to examine the relationship between family EE-criticism, patient perceived criticism and criticism sensitivity and psychiatric disorders following moderate to severe traumatic brain injury (TBI). Participants were 60 patients with TBI and their family members. Patients were assessed for psychiatric disorders using the Structured Clinical Interview for DSM-IV (SCID-I) and completed the Perceived Criticism Measure (PCM) to determine levels of perceived criticism and criticism sensitivity. Family members completed the Family Questionnaire (FQ) to assess patient directed EE-criticism. Patients were reassessed approximately 12-months post-baseline. After controlling for diagnostic status at baseline, high criticism sensitivity at baseline was associated with greater probability of psychiatric diagnosis at follow-up (odds ratio=3.99, 95% CI=1.15-13.71). Family EE-criticism and perceived criticism were not predictive of patient diagnostic status at follow-up, but patients with high EE-family members were more likely to have a concurrent psychiatric diagnosis at baseline. Findings suggest that sensitivity to interpersonal criticism may have a role in the development and course of psychiatric disorders following TBI.

The Evolution of Post-Traumatic Stress Disorder following Moderate-to-Severe Traumatic Brain Injury.

Increasing evidence indicates that post-traumatic stress disorder (PTSD) may develop following traumatic brain injury (TBI), despite most patients having no conscious memory of their accident. This prospective study examined the frequency, timing of onset, symptom profile, and trajectory of PTSD and its psychiatric comorbidities during the first 4 years following moderate-to-severe TBI. Participants were 85 individuals (78.8% male) with moderate or severe TBI recruited following admission to acute rehabilitation between 2005 and 2010. Using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Disorders (SCID-I), participants were evaluated for pre- and post-injury PTSD soon after injury and reassessed at 6 months, 12 months, 2 years, 3 years, and 4 years post-injury. Over the first 4 years post-injury, 17.6% developed injury-related PTSD, none of whom had PTSD prior to injury. PTSD onset peaked between 6 and 12 months post-injury. The majority of PTSD cases (66.7%) had a delayed-onset, which for a third was preceded by subsyndromal symptoms in the first 6 months post-injury. PTSD frequency increased over the first year post-injury, remained stable during the second year, and gradually declined thereafter. The majority of subjects with PTSD experienced a chronic symptom course and all developed one or more than one comorbid psychiatric disorder, with mood, other anxiety, and substance-use disorders being the most common. Despite event-related amnesia, post-traumatic stress symptoms, including vivid re-experiencing phenomena, may develop following moderate-to-severe TBI. Onset is typically delayed and symptoms may persist for several years post-injury.

FACTORS ASSOCIATED WITH POSTTRAUMATIC STRESS DISORDER FOLLOWING MODERATE TO SEVERE TRAUMATIC BRAIN INJURY: A PROSPECTIVE STUDY.

BACKGROUND: This study prospectively examined the relationship between preinjury, injury-related, and postinjury factors and posttraumatic stress disorder (PTSD) following moderate to severe traumatic brain injury (TBI). METHOD: Two hundred and three participants were recruited during inpatient admission following moderate to severe TBI. Participants completed an initial assessment soon after injury and were reassessed at 3, 6, and 12 months, 2, 3, 4, and 5 years postinjury. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-fourth edition was used to diagnose pre- and postinjury PTSD and other psychiatric disorders. The Glasgow Outcome Scale-Extended (GOSE) and the Quality of Life Inventory (QOLI) were used to evaluate functional and psychosocial outcome from 6 months postinjury. RESULTS: The frequency of PTSD ranged between 0.5 and 9.4% during the 5-year period, increasing throughout the first 12 months and declining thereafter. After controlling for other predictors, shorter posttraumatic amnesia duration (odds ratio = 0.96, 95% CI = 0.92-1.00), other concurrent psychiatric disorder (odds ratio = 14.22, 95% CI = 2.68-75.38), and lower GOSE (odds ratio = 0.38, 95% CI = 0.20-0.72) and QOLI scores (odds ratio = 0.97, 95% CI = 0.95-0.97) were associated with greater odds of having injury-related PTSD. DISCUSSION: The results of this study indicate that while shorter posttraumatic amnesia duration is associated with PTSD, greater TBI severity does not prevent PTSD from evolving. Patients with PTSD experienced high rates of psychiatric comorbidity and poorer functional and quality of life outcomes after TBI. CONCLUSION: There is a need to direct clinical attention to early identification and treatment of PTSD following TBI to improve outcomes.

Expressed emotion and its relationship to anxiety and depression after traumatic brain injury.

Levels of expressed emotion (EE) within the family, particularly criticism and emotional over-involvement, are associated with a patient's psychological outcome in a range of psychiatric and medical conditions. This study aimed to examine the relationship between levels of family EE and anxiety and depression in patients who have sustained a traumatic brain injury (TBI). A further aim was to examine whether family members' levels of psychological distress and attributions of patient symptom controllability, were related to their levels of patient-directed EE. Participants were 43 patients who had sustained a complicated mild to severe TBI three months to five years previously, and their nominated family members. Results indicated that family members' criticism and emotional over-involvement were associated with patients' levels of anxiety and depression. Moreover, family members' levels of anxiety and depression were associated with their levels of patient-directed criticism and emotional over-involvement, whilst their attributions of patient symptom control were not. These findings suggest that levels of EE within the family are associated with psychological adjustment following TBI. Consequently, interventions targeting EE in family members may help to reduce psychiatric difficulties following TBI.